Young Queens

Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Race/Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
example@example.com
Which tour date would you prefer?

March 22nd -26th, 2022April 19th - 23rd, 2022
Which region are you interested in visiting?

Down SouthEast Coast
Please upload a copy of the following: (1) Student's ID card, (2) Student's medical insurance card, and (3) copy of their transcript.*

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Do you have access to the following technology tools necessary to engage in this program? Please select all that apply.*

Zoom enabled deviceReliable Computer access capabilityStrong internet connection capabilityAccess to emailAccess to a mobile device (smart phone)
How did you hear about the Life Enrichment Group?
Best day(s) and time(s) of the week to contact?*
Please explain why you want to attend a Know to Grow College Tour. What do you hope to gain? Write a minimum of 5-7 sentences.*
Parent/Guardian Information
Name*

First NameLast Name
E-mail*
Cell Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household size (# of adults and # of children)*
Does your student(s) have any allergies, chronic illness, or medical conditions? If yes, please describe.*
School Information
School*
Grade (for the current year)*
Free/reduced lunch?*
Does your student have any of the following?*
Do you have access to your grades?*
If yes, please add your student log in information for grade checks.
Any other information regarding school we should know?*
Favorite subject in school and why?*
Least favorite subject in school and why?
Photo/video release
I understand that, unless noted below; photos, video, or audio recordings of participant during Life Enrichment Group (L.E.G) events and programming may be used without compensation to promote the L.E.G. I understand that my child’s name may be revealed in descriptive text or commentary. Please initial.*
L.E.G has permission to take video/pictures of my child. Select one.*

YesNo
Date*

MonthDayYear
Date
Signature of student*

Clear
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Youth's signature and acknowledgement of reading and agreeing to the code of conduct listed above. *

Clear
Parent/Guardian Name*

First NameLast Name
Relationship to participant:*
Preferred Phone Number*

Area CodePhone Number
Email*
example@example.com
Home Address (If different from above.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Relationship to Participant
Preferred Phone Number

Area CodePhone Number
Email
example@example.com
Allergies:

No known allergies.
This participant is allergic to:

FoodMedicineThe environment (insect stings, hay fever, etc.)This participant has a life-threatening allergy. (Note: An emergency care plan signed by a physician is required. Please describe below, in detail, what the participant is allergic to, the reaction seen & any preventative or responsive measures utilized (i.e. medication). Upload additional forms below if necessary.Other
Please upload any additional forms.

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If you selected food, please list which ones.
If you selected medicine, please list which ones.
If you selected environment, please list.
Immunizations:*

My child is up-to-date on his/her immunizations and tetanus shots as required by Washington State law.My child has an immunization exemption on file with his/her school. I understand and accept the risks to my child from not being fully immunized.
Medication:*

This participant will not take any daily medications while attending the activities.This participant will be self-administering the following daily medication(s) while attending the activities:
Does the participant require accommodations for a disability in order to access or participate in activities?*
What have we forgotten to ask? Please provide in the space below any additional information about the participant that you think is important or that may affect his or her ability to fully participate in the program. Attach additional information if needed.*
Upload additional information if needed.

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I voluntarily sign this authorization in consideration for permission for my child(ren) to participate in the Life Enrichment Group. I have read it, and I understand its content and significance.

Signature Date
Signature of Parent/Guardian (For participant less than 18 years of age)

Signature Date
Signature of Participant (For participant 18 years of age or older)

Parent/Guardians: Keep a copy for your records.
Primary Doctor:*
Phone Number:*

Area CodePhone Number
Medical Alerts:*
Insurance Company:*
Policy Number:*
Signature of Parent/Guardian:*

Clear
Parent/Guardian (Please print):*

First NameLast Name
Date*

MonthDayYear
Date
Witness Signature:

Clear
Witness Name (please print):

First NameLast Name
Date

MonthDayYear
Date
Signature Date
I, Name of Parent/Guardian have read the Code of Conduct.

Parent/Guardian Signature Date
I understand that I am responsible for my child’s behavior and will be responsible for all costs and expenses should my student not adhere to the code of conduct. I give permission to the staff in charge to administer the code. I understand what is being asked and expected of my student. I, * have read the Code of Conduct.
Should be Empty:

School Information

Photo/video release