Youth 360 Registration

Youth 360 Program

Please fill out the registration form below
Student Name *

First Name Middle Name Last Name
Phone Number

Area Code Phone Number
Parent Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Emergency Contact *
First & Last Name
Emergency Phone Number *

Area Code Phone Number
Birth Date *

Month Day Year
Gender
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
What School do you attend? *
What grade are you in? *
Student E-mail
Twitter
@Urbanfam_1
Facebook
@Urbanfamily
Are you involved in other programs? Yes or No? If yes, please list what program(s)? *
Example: Yes,
What type of programs are you interested in? *

Job Readiness & Paid Internships Mentor Groups & Life Coaching Academic Program Leadership Development Sports Training & Development Entrepreneur & Business Development
What type of support services do you need? *

Housing Support Court Support & Advocacy School Support Drugs & Alcohol Support Family Support Job & Career Support
What would be helpful for us to know about you? *
MEDICAL RELEASE

Terms and Conditions
I hereby give consent to the Urban Family Center and its staff or representative permission for medical consent and treatment of my student?
LIABILITY RELEASE

Terms and Conditions
By completing and signing this electronic form/and or hard copy form I the undersigned parent/guardian of the above listed minor (if participant is under the age of 18) acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue the Urban Family Center, their directors, officers, employees, managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the Programs and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize.
MEDIA RELEASE

Terms and Conditions
I hereby give consent to Urban Family Center to take photos, videos and digital images of my child for use in our program marketing and reports as we deem necessary.
Signature

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Youth 360 Program

MEDICAL RELEASE

LIABILITY RELEASE

MEDIA RELEASE