Youth Department Registration Form

Check one or all

After School_____

Summer Camp______

Dream Keepers_____

Incomplete registrations will not be accepted.

All information released below is confidential and will not be given out.

Part 1 – YOUTH INFORMATION:(All information must be completely filled out)

Last Name:______First Name:______LastGrade Completed:______Race: ______Male/Female

Birth Date (mo/day/yr):____/____/_____ Age: ______School: ______

T-Shirt sizeChild Small_____ Child Medium_____Child Large_____ Adult Small_____ Adult Medium_____

Adult Large______Adult XLarge______

Does your child qualify for FREE or REDUCED Lunch? Yes/No

Does your child qualify for CCDF? Yes/No

Is your Child a Twenty First Century Scholar?Yes/No

Does student have any of the following disabilities?Yes/No

Physical

Mental

Emotional

Combination of Above (Explain):______

Part 2 – PARENT/GUARDIAN INFORMATION:

Name of Primary Guardian(s):______Relationship to Youth:______

Birth Date (mm/dd/yyyy)____/____/_____ SSN______Email Address______

Street Address:______Zip Code:______

Day Phone Number: ( )______Evening Phone Number: ( )______

Work Phone Number: ( )______Pager/Cell Phone Number: ( )______

Number of brothers and Sisters in same household: ______

Part 3 – EMERGENCY CONTACT INFORMATION:

Name of Contact: ______Relationshipto Student:______

Street Address______ZipCode: ______

Day Phone Number: ( ) ______Evening Phone Number ( )______

Work Phone Number: ( ) ______Pager/Cell Phone Number ( ) ______

Part 4 – HOUSEHOLD INFORMATION (PLEASE CIRCLE ONE):

(The following information is required by those who fund our programs and is therefore required in the application)

Total Estimated Household Income: Household Makeup:

Below $10,000Single Parent Household / Mother

$10,000 – $14,999Single Parent Household / Father

$15,000-$19,000Two Parent Household

$20,000-$29,999Grandparent(s)

Over $30,000Other

Part 5 – MEDICAL INFORMATION:

Doctor’s Name:______Clinic ______

Address:______Clinic Phone Number:______

Medical/Hospital Insurance:______Policy/Group Number:______

Does your student have allergies (Explain): ______

Does he/she have medial problem (Explain): ______

Does he/she take medication (List): ______

Part 6 – INSURANCE INFORMATION:

Does your child Receive Medicaid: YES/NO If yes, what is your Medicaid #:______

Do you receive AFDC/TANFIf yes, what is your AFDC/TANF #:______

Are you presently with a private insurance carrier, if so, please give name:______

Part 7 – WAIVER, RELEASE OF LIABILITY, AND CONSENT FOR MEDICAL TREATMENT

IN EXCHANGE FOR MY BEING ALLOWED TO PARTICIPATE IN ______, I, AND IF I AM NOT YET 18 YEARS OLD, MY PARENT OR LEGAL GUARDIAN (INDIVIDUALLY AND COLLECTIVELY REFERRED TO BELOW IN THE FIRST PERSON SINGULAR) AGREE TO BE BOUND BY EACH OF THE FOLLOWING:

  • OBLIGATION TO INSPECT FACILITIES AND EQUIPMENT: I AGREE THAT PRIOR TO PARTICIPATING IN THE ACTIVITY, I WILL INSPECT THE FACILITIES AND EQUIPMENT TO BE USED. IF I BELIEVE ANYTHING TO BE UNSAFE, I WILL IMMEDIATELY NOTIFY THE PROGRAM STAFF/INSTRUCTOR.
  • ASSUMPTION OF RISK: I ASSUME ALL RISKS, KNOWN AND UNKNOWN, IN ANY WAY CONNECTED WITH MY PARTICIPATION IN THE ACTIVITY. I ACCEPT PERSONAL RESPONSIBILITY FOR ANY LIABILITY, INJURY, LOSS OR DAMAGE IN ANY WAY CONNECTED WITH MY PARTICIPATION IN THE ACTIVITY.
  • WAIVER AND RELEASE: I WAIVE AND RELEASE THE CENTER FROM ALL CLAIMS FOR ANY LIABILITY, INJURY, LOSS, OR DAMAGE RESULTING FROM MY PARTICIPATION IN THE ACTIVITY.
  • CONSENT TO MEDICAL TREATMENT: I AGREE THAT THE CENTER MAY PROVIDE TO ME, THROUGH
  • MEDICAL PERSONNEL OF ITS CHOICE, CUSTOMARY MEDICAL OR TRAINING ASSISTANCE,
  • TRANSPORTATION AND EMERGENCY MEDICAL SERVICES. THIS CONSENT DOES NOT IMPOSE A DUTY UPON THE CENTER TO PROVIDE SUCH ASSISTANCE, TRANSPORTATION, OR OTHER SERVICES.
Media Participation

I give permission for my child to participate in all photographs, videotapes, and interviews, which promote the programs of ForestManorMulti-ServiceCenter and its youth program activities.

I HAVE READ THIS WAIVER, RELEASE, AND CONSENT. I UNDERSTAND THAT I HAVE GIVENUP SUBSTANTIAL RIGHTS BY SIGNING IT. I AM SIGNING THIS WAIVER, RELEASE, AND CONSENT VOLUNTARILY.

Today’s Date: ______

Signature of Parent of Guardian: ______