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Program Registration
Contact Information
Child's Name
*
First Name
Last Name
Date of Birth
*
(mm/dd/yyyy)
Grade
*
select one
5
6
7
8
9
10
11
12
GED
School
*
Race
*
select one
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Gender
*
select one
Male
Female
Home Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Parent / Guardian Contact Information
*
First Name
Last Name
Email
*
Verify Email
*
Phone
*
Member Information
The following information is necessary for our records and the funding our organization receives. The answers you provide are completely confidential. Your cooperation in providing this information is both appreciated and necessary.
My child has been involved in the foster care system.
*
select one
Yes
No
My child has been involved with the juvenile justice system.
*
select one
Yes
No
My child has friends or family members that have been involved in criminal behavior or gang associations.
*
select one
Yes
No
My child has been suspended from school or truant from school.
*
select one
Yes
No
My child has excessive absences from school.
*
select one
Yes
No
My child is currently functioning below the appropriate grade level for their age.
*
select one
Yes
No
My child has a learning disability.
*
select one
Yes
No
My child is currently on the Free or Reduced Lunch Program.
*
select one
Yes
No
Health & Emergency Information
Primary Emergency Contact
*
Phone
*
Secondary Emergency Contact
Phone
List All Medical Problems, Warnings, Allergies and Special Needs
Consents & Acknowledgments
Emergency Treatment
*
In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by Truly Valued, Inc. to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery for my child as named above.
select one
Yes
No
Transportation & Field Trips
*
I give permission for my child to utilize the transportation (if applicable) provided by Truly Valued, Inc. and to participate in all field trips provided / sponsored by Truly Valued, Inc
select one
Yes
No
Participation in Prevention / Intervention Programs
*
Truly Valued, Inc. offers Prevention / Intervention Programs. These are prevention programs that encourage all members to make smart, positive, healthy choices in life. The programs strive for participants to; identify and resist peer and media pressure for involvement in negative behavior and understand the consequences of negative decision-making. Participants will gain understanding of the physical and social changes taking place in their lives, as well as improve decision-making skills, learn goal setting, problem solving and relationship building. I understand the purpose of these programs and give permission for my child to attend.
select one
Yes
No
Photo Release
*
I give permission Truly Valued, Inc. to take photos/video of my child and then to use these for publicity purposes and to meet grant reporting requirements.
select one
Yes
No
School Record
*
I give permission to release to Truly Valued, Inc. any school information such as: grades, behavior and any other school reports necessary to assist in their programming.
select one
Yes
No
Parent / Guardian Consent
*
I approve my child joining Truly Valued, Inc. and agree not to Truly Valued, Inc., its Board of Directors, Staff or Volunteers responsible and/or liable, and hereby RELEASE INDEMNITY AND HOLD THEM HARMLESS from liability for losses of any personal property and for injuries or by accidents suffered by my child at a Truly Valued, Inc. or in connection with membership, travel or participation, including any injury or loss caused by or claimed to be caused by the negligence, whether in whole or in part. I ATTEST that the information provided is true and accurate.
select one
Yes
No
