Youth Permission Form

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!
Participant Name *

First Name Last Name
Age *
Date of Birth *

Month Day Year
School

Roosevelt South Washburn Sanford Folwell Northrop El Colegio Field Keewaydin Friendship Academy Hiawatha Academy
School
Grade *
Health Concerns / Emotional Needs *
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.
Gender Identity

Male Female Transgender Female Transgender Male Gender Queer
Racial Identity

Black/African American/African Latinx Indigenous Asian/Asian American White Hawaiian/Pacific Islander Multi-Racial
Is your family eligible for free or reduced lunch?

Yes No I don't know

Primary Contact Information
Parent/Guardian 1 *

First Name Last Name
Mobile Phone *

- Area Code Phone Number
Would you like to receive text updates about what's happening at heARTS? *

Yes No
Home Phone

- Area Code Phone Number
E-mail *

Address *

Address (if different from above)

Emergency Information
Emergency Contact *

First Name Last Name
Relationship to Participant *
Phone Number *

- Area Code Phone Number
Primary Physician/Clinic
This information is requested in the case of a medical emergency.

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.
Participant Exit Options *

I give permission for my child to leave heARTS unaccompanied. I do not give permission for my child to leave heARTS unaccompanied and will notify heARTS if someone other than a guardian is picking up.
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.
I give consent for photo and media release. *

Yes No
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.
I give consent for medical treatment. *

Yes No

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.
Parent/Guardian Signature *

First Name Last Name
Today's Date *

- Month - Day Year
Newsletter

Yes, subscribe me to heARTS' newsletter.
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