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?

Which region are you interested in visiting?

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

Browse Files

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

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

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?

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.

Date

Signature of student

Signature of Parent/Guardian

Date

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

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:

This participant is allergic to:

Other

Please upload any additional forms.

Browse Files

If you selected food, please list which ones.

If you selected medicine, please list which ones.

If you selected environment, please list.

Immunizations:

Medication:

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.

Browse Files

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:

Parent/Guardian (Please print):

First NameLast Name

Date

Witness Signature:

Witness Name (please print):

First NameLast Name

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.

School Information

Photo/video release