Language
  • English (US)
  • Español
  • Youth Permission Form

    courageous heARTS offers a safe, drop-in space for youth during after school and summer hours. To register for participation, we simply ask that young people have this form completed by a parent or guardian once per year. Then attend whenever you can!

  • Demographic Information

    The information requested below is optional and will be used to understand the general composition of our community and ensure we maintain safe space and inclusive practices for all.



    • Primary Contact Information  
    •  -
    •  -
    •  -
    •  -
    • Emergency Information  
    •  -
    • Permissions  
    • TRANSPORTATION TO AND FROM PROGRAMMING | I understand that courageous heARTS does not provide transportation. I will make arrangements as a family to ensure my child's ability to participate.

    • CONSENT FOR PHOTO AND MEDIA RELEASE | I understand my child's image may be taken by photograph or video during programming and other special events. I grant permission for heARTS to publish my or my child's photograph or likeness in promotional publications (print, digital, or video formats) and to the media to promote the organization.

    • CONSENT FOR MEDICAL TREATMENT | As the parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

    • Signature & Payment  
    • By signing below, you grant permission for your child to attend programming, events, field trips, and service projects associated with courageous heARTS. You also agree to hold heARTS harmless for accidents or loss/damage of personal property.

    •  -  - Pick a Date
    •    
    • Should be Empty: