Youth Forms

Please fill out a form for EACH child. Thanks!

Preferred Center / Link 2 Feed #

Program Name: *

Child First Name *

Child Last Name *

Child Birthdate *

Child Grade *

Child Age *

Gender *

Male
Female
Other

Medical Information – If your child needs to take medication during our program, please talk to the program staff.

Medical Conditions (If applicable)

Allergies (If applicable)

If Allergies Exist, Type of Reaction

Medical Self Administration (If applicable)

Please Select all that apply (According to 55 Pa. Code § 3800.189 – Self-administration of medications)

EpiPen
Inhaler
Authorized Self-Administration

Parent/Guardian Typed Signature *

Date / Time

Child Ethnicity *

Child Language *

Hispanic *

Yes
No

Housing Type *

Rent
Own
Homeless

Gross Household Monthly Income $ *

Health Insurance *

Insured
Under-Insured
No Insurance

Health Insurance Company *

Policy Number *

Physician *

Physician Office Phone *

1. Parent/Guardian Name: *

Phone Number *

Email *

Street Address with City, State, and ZIP Code *

2. Parent/Guardian Name:

Phone Number:

Email

Street Address with City, State, and ZIP Code

4. Additional people who can pick up my child: (Name and phone number) *

Only fill out below if your child is registering for our Summer Day Camp Program

For your child’s safety and our knowledge, rate your child’s swimming ability (circle one)

I give permission for my child to attend and participate in New Hope Ministries’ Youth Programs, and all of the activities. I give permission for my child to go on all field trips and social activities sponsored by New Hope Ministries. I also give permission for my child to ride in any vehicle designated by the adult in whose care the youth has been entrusted while attending and participating in the programs offered by New Hope Ministries. In case of a medical emergency, I authorize emergency medical care or dental care, or both if I cannot be reached, and agree to pay all such medical expenses which may not be covered by my medical card or other insurance. *

I give permission as stated above.

I also give New Hope Ministries permission to use any photographs, video recordings, my story, my name, and/or my child(ren)’s for publication in fundraising, and/or public relations efforts such as newsletters, brochures, newspaper articles, displays, videos, our website, etc. This agreement includes materials provided by me, my children, or taken by or on behalf of New Hope Ministries. *

I give permission as stated above.

By typing my name below, I acknowledge that I am electronically signing this form and that the information provided is true and accurate to the best of my knowledge. *

Date / Time *

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Youth & Teen Permission Form:

Please fill out a form for EACH child. Thanks!

Medical Information – If your child needs to take medication during our program, please talk to the program staff.

Medical Self Administration (If applicable)

Only fill out below if your child is registering for our Summer Day Camp Program