Date *
Date
Program Site *
At which site will your student participate?
Program *
In which program will your child participate?
Applicant's Name *
Applicant's Name
Gender *
Student Phone
Student Phone
Date of Birth *
Date of Birth
Home Address *
Home Address
Allergies *
Restricted Access
Parent/Guardian Information
Name
Name
Phone *
Phone
Are there siblings between the ages of 6 to 18 at this household? *
Acceptable Alternative Drop-off Address and Alternative Pick-up
*Please call Freedom for Youth Ministries to inform the site coordinator if your students will be dropped off at the alternative address or picked up by that person.
Name
Name
Phone
Phone
Address
Address
Emergency Contact Information and Release
A person Freedom for Youth can contact should we not be able to get a hold of the parent/guardian.
Name *
Name
Phone *
Phone
Discipline Policy
When unacceptable behavior such as inappropriate language, physical or verbal aggression, showing disrespect to peers or staff and volunteers is displayed, students will be redirected by staff or volunteers. Positive verbal communication along with some time given to correct the behavior, shall accompany the redirection. On occasions when redirection is unsuccessful in resolving negatime behavior, the child's parents/guardians will be notified, and the child will be removed from the program for a time to be determined by the Freedom for Youth Program Coordinator.
School Information
Special Education Services
Does your student receive special education services at their school?
Other Services
Is the student currently working with a success manager or behavior/at-risk counselor in school?
School Communication Authorization *
I authorize the release of student-specific data to Freedom for Youth and its designated volunteers from teachers/school counselors about grades, homework assignments, and attendance information as necessary to assist with academic needs. This may include test data and assessments, checking grades online, having a schedule of homework assignments, and attending parent/teacher conferences as needed.
Additional Approvals
Check to approve the following.
Events *
I approve of my child being transported to and attending the activities, events, field trips, and service projects associated with Freedom for Youth that will include traveling with staff or volunteers both on and off the Freedom for Youth site.
Photo Release *
I hereby voluntarily and without compensation authorize Freedom for Youth to include images of my child in photographs, movies, videotapes, and PowerPoint presentations on the condition that the materials will be used for the purpose of community education or program promotion only. Freedom for Youth and its employees will not use these materials for compensation. This grant of permission shall only be revoked by a written instrument delivered to the Director of Programming at Freedom for Youth. This consent shall remain in effect, unless revoked.
Lost or Stolen Items *
I agree that Freedom for Youth Ministries is not responsible for any lost, stolen, or damaged items.
Middle & High School Students
Release of Liability
I understand that the student may participate in classes where power equipment and power tools are used and I agree that Freedom for Youth cannot be held responsible for accidents that may occur because of my child failing to follow the safety rules and procedures taught in class.
Approval *
By checking this box, and entering my name and the date, I agrree to hold harmless Freedom for Youth Ministries, its employees, board members, and volunteers against any and all claims, demands, suits, liabilities, and expenses, including attorney's fees, arising out of or related in any way to the services or transportation provided under this program. I specifically waive and release any and all liability, claims, demands, actions, and causes of action, present and future, against Freedom for Youth Ministries and its staff or volunteers, arising out of Freedom for Youth Ministries related activities.
Signature of Parent/Guardian *
Signature of Parent/Guardian
Date *
Date
Signature of Student
Signature of Student
Date *
Date