Forms - Kidz With Hope

If you are interested in enrolling your child, please complete the following documents

Student Name:

DOB

Please Select

Male Female

Parent Guardian Contact:
Primary Contact

Name of Parent

Relationship

Telephone #

Secondary Contact

Name of Parent

Relationship

Telephone #

Medical Information

Allergies:

Insects:

Use of Epi Pen

Yes No

Other Allergies:

Asthma

Yes No

Inhaler

Yes No

Uses it independently ?

Yes No

Other Health Issues:

I give my child permission to walk home from Kidz with Hope Youth Organization Incorporated’s activities.

I give permission for Kidz with Hope Youth Organization Inc., to see my child’s report card in an effort to encourage him/her for their academic achievement.

Photograph/Video Release

I authorize Kidz with Hope Youth Organization Incorporated, or its designee, to edit, modify, copy, and use any photographs or videos of my child for promotional purposes.
I authorize the lawful use of photographs or videos of my child in media including, but not limited to, websites, magazines, journals, books, articles, and social media.
I agree that, once lawfully used, photographs or videos of my child will become the sole property of Kidz with Hope Youth Organization Incorporated, and I will have no ownership rights to them.

Signature

Date

Student

DOB:

Address:

Telephone:

I authorize my child to be dropped off at the following location:
Kidz with Hope Youth Organization, Inc After School Program
716 Gilbert Street, Durham, NC

Please drop my child there on the following school days: (please check)

Tuesday Wednesday Thursday

This will begin on the following date:

Signature

Parent/Guardian Telephone:

I give approval for my child

To participate in the field trip sponsored by Kidz with Hope Youth Organization Incorporated.

Field Trip Location:

Date of Trip:

Leave Time

Estimated Return:

I understand that my child will be supervised with appropriate safety measures. In an emergency, I authorize Kidz with Hope Youth Organization, Incorporated, to take my child to the nearest emergency room or hospital and allow hospital staff to provide any treatment a physician considers necessary for my child’s well-being.

Please check one of the following:

I will pick up my child when my child returns.

I will give my child permission to walk home when the trip ends.

Parent Signature

Date

Parent Telephone Number:

Best way of communicating: (check appropriate)

Text Call