Youth Enrollment Application

1
Which Youth Program are you interested in?* This field is required.
Bethune Girls Club (ages 6-14)
DuBois Boys Club (ages 6-14
Drumming Class (ages 9-13}
Distinguished Gentlemen of Spoken
Word (ages 13-18}
Minority Youth Leadership (ages 13-18)
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How did you hear about us?* This field is required.
Friend
Parent
Relative
Teacher
Pastor
Social worker
Internet search
Social Media
Email Blast
Cleveland UMADAOP Website
3
Youth Name:* This field is required.
First Name
Last Name
4
Youth Age:* This field is required.
5
Gender:* This field is required.
Male
Female
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Birth Date* This field is required.
Month
Day
Year
7
Race:* This field is required.
African American/ Black
Caucasian/ White
Hispanic/Latino
Other
8
School:* This field is required.School or College youth goes to:
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Student Email:
example@example.com
10
Parental Status:* This field is required.
Both Living
Both Deceased
Mother Deceased
Father Deceased
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Parent/Guardian Name:* This field is required.Perent or Guardian completing this form
First Name
Last Name
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Mother's Name
First Name
Last Name
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Father's Name
First Name
Last Name
14
Guardian's Name
First Name
Last Name
Relationship
15
Address* This field is required.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Parent Phone Number* This field is required.
Area Code
Phone Number
17
Alternate Phone Number
Area Code
Phone Number
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Parent Email:* This field is required.
example@example.com
19
Parent's Race* This field is required.
African American/ Black
Caucasian/ White
Hispanic/Latino
Other
20
Employment Status:* This field is required.
Full-Time
Part-Time
Retired
Unemployed
21
Medical Conditions (Please check all that apply)
Asthma
Diabetes
High Blood Pressure
Migraine Headache
Epilepsy
Drug Use
Alcohol Use
Sickle Cell Disease
Gastro Intestinal Problems
22
Has your child had any medical experience in any of the following?* This field is required.Please answer yes or no.
Yes
No
Any evidence of hearing loss/difficulties?
Any evidence of vision difficulties?
History of diabetes in the family?
Surgeries?
Hospitalization?
Physical handicaps?
Mental health break-downs?
Other illnesses?
Does child wear corrective shoes?
Should activities be limited?
Any evidence of hearing loss/difficulties?
Any evidence of vision difficulties?
History of diabetes in the family?
Surgeries?
Hospitalization?
Physical handicaps?
Mental health break-downs?
Other illnesses?
Does child wear corrective shoes?
Should activities be limited?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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If yes, please explain your child medical experience:
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Special Diet:* This field is required.Please indicate any special dietary needs of your child, answer yes or no.
Yes
No
Vegetarian
Seafood Vegetarian
Poultry Vegetarian
No Dairy Products
No Red Meat
No Pork
No Sugar
Vegetarian
Seafood Vegetarian
Poultry Vegetarian
No Dairy Products
No Red Meat
No Pork
No Sugar
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Food Allergies: (Check all that apply)* This field is required.Please answer yes or no.
Yes
No
Milk
Fruit
Nuts
Grain
Wheat
Vegetables
Meats
Milk
Fruit
Nuts
Grain
Wheat
Vegetables
Meats
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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If you selected yes for any Food Allergies, please explain:Please specify any vegetables or meats.
27
Substance/Drug Allergies:* This field is required.Please answer yes or no.
Yes
No
First Aid Products
Soaps
Lotions/Oils
Deodorant
Wheat
Aspirin
Rubbing alcohol
Peroxide
Iodine
Cough Syrups
Clothing
Hair Products
First Aid Products
Soaps
Lotions/Oils
Deodorant
Wheat
Aspirin
Rubbing alcohol
Peroxide
Iodine
Cough Syrups
Clothing
Hair Products
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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If you selected any Substance/Drug Allergies, please explain:Please specify any clothing or hair products.
29
Insects/Animals/Plants (check all that apply):* This field is required.Please answer yes or no.
Yes
No
Bee Sting
Flea Bites
Worms
Dogs
Cats
Hay
Grass/Ragweed
Bee Sting
Flea Bites
Worms
Dogs
Cats
Hay
Grass/Ragweed
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Signature
31
{youthName} {birthDate}

Child's Social Security Number:
Should be Empty: