Youth Permission Form

Participant Name *

First Name Last Name
Date of Birth *

Month Day Year
Pronouns *

She/Her/Hers He/Him/His They/Them/Theirs

Home Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

School *

Roosevelt South Washburn Sanford Folwell Northrop El Colegio Field Keewaydin Friendship Academy Hiawatha Academy
Grade

5th 6th 7th 8th 9th 10th 11th 12th
Are there any physical or mental health concerns we should be aware of?
Parent Name *

First Name Last Name
Mobile Phone *

Area Code Phone Number
E-mail
Emergency Contact Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to Participant *
Primary Physician/Clinic
This information is requested in the case of a medical emergency.
Optional Demographic Information
Gender Identity

Male Female Transgender Female Transgender Male Gender Nonconforming
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 or other forms of public assistance?

Yes No I don't know

Photo / Media Consent

I understand my child's image may be taken by photograph or video while at the studio or 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 emergency medical treatment.

Yes No
Release from the Studio

Youth attending heARTS have a wide range of autonomy. Please indicate what level of independence you would like for your child's release from the studio. You are welcome to adjust this option at any time.
Please select from the following release 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.
Newsletter

Yes, subscribe me to heARTS' e-mail newsletter.
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.
Please sign with your finger or curser in the box below: *

Clear
Date

Month Day Year Date Picker Icon
Should be Empty:

Optional Demographic Information

Photo / Media Consent

Consent for Medical Treatment

Release from the Studio