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 *

Does your child have allergies to (click all that apply): *

If other, please explain:

Has your child experienced any of the following (check all that apply): *

If other, please explain:

Is your child currently on any medications? *

Yes
No

If yes, please explain:

Date of last tetnus shot: *

Should this child’s activities be restricted for any reason? *

Yes
No

If yes, please explain:

We will be going off site at times for field trips / activities. Children attending our programs need to be self-sufficient.

Please upload youth picture

Drop your file here or click here to upload You can upload up to 1 files.

1. Parent/Guardian Name: *

Phone Number *

Email *

Street Address with City State and Zip Code *

2. Parent/Guardian Name:

Email *

Phone Number:

Street Address: *

City, State, Zip *

3. Emergency Contact: *

Emergency Contact Phone Number: *

Emergency Contact Email *

Emergency Contact (Relationship to Child): *

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

Gender of Child: *

Ethnicity of Child: *

Language of Child: *

Hispanic (Yes or No) *

Housing Type (choose one):

Rent
Own
Homeless

Gross Household Monthly Income *

Health Insurance (choose one): *

Insured
Under-insured
No insurance

Health Insurance Company *

Health Insurance Policy Number *

Physician Name *

Physician Office Phone *

Dentist *

Dentist Office Phone *

I give permission for my child to attend and participate in New Hope Ministries’ 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 the event of an accident or injury to my child, I will not hold New Hope Ministries, Inc., its employees and volunteers, host church or other meeting places responsible or liable. 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 further agree to hold harmless and reimburse New Hope Ministries, its employees, volunteers, host church, or other meeting places for any liability caused by the negligent, willful or intentional acts of my child. It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required, but is given to provide authority and power of the part of the supervisor and his/her authorized designee, to exercise his/her best judgment on what is advisable for my child’s care, upon advice of such physician, dentist, and surgeon. If my child has a fever or is exhibiting COVID-19-like symptoms, I will not bring them to the program, and New Hope has permission to send my child home. I also give New Hope Ministries permission to use any photographs, video recordings, my story, my name, and/or my children’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. *

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Kids Adventure Club Registration Form:

Please fill out a form for EACH child. Thanks!

We will be going off site at times for field trips / activities. Children attending our programs need to be self-sufficient.