Student Information

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

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

Medical Information

Photograph/Video Release