Truly Valued · Program Registration

Contact Information

Child's Name

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Grade

*

School

*

Race

*

Gender

*

Home Address

*

Address Line 1

Address Line 2

City

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.

*

My child has been involved with the juvenile justice system.

*

My child has friends or family members that have been involved in criminal behavior or gang associations.

*

My child has been suspended from school or truant from school.

*

My child has excessive absences from school.

*

My child is currently functioning below the appropriate grade level for their age.

*

My child has a learning disability.

*

My child is currently on the Free or Reduced Lunch Program.

*

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.

Transportation & Field Trips

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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

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.

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.

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.

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.