J.U.M.P. PARTICIPANT INTAKE FORM

J.U.M.P.’s Adventure IRL!
I am applying for a need based scholarship for my child.

YesNo
Participant Name*

First NameLast Name
Gender*

MaleFemaleTransgenderPrefer Not to AnswerOther
My child's pronoun preference is:*

he/himshe/herthey/themPrefer Not to AnswerOther
Date of Birth*

MonthDayYear
Date
Current Grade Level*
What language is primarily spoken in your home?*

EnglishSpanishOther
Ethnicity*
Race*
Race: Other
Height
Weight
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Size*
Parent or Guardian Name

First NameLast Name
Relationship
Parent or Guardian Phone Number (cell)

Area CodePhone Number
Parent or Guardian Phone Number (other)

Area CodePhone Number
Parent or Guardian Email
example@example.com
Alternative Emergency Contact Name

First NameLast Name
Alternative Emergency Contact Phone Number (cell)

Area CodePhone Number
Alternative Emergency Contact Phone Number (other)

Area CodePhone Number
Insurance Coverage

Participant is responsible for his or her own medical expenses. Insurance is required for participation. The information requested below is for the primary family policy holder.
Name of Health Insurer
Policy Number
Name of Primary Care Physician
Physician Contact Information
Signature Required

Permission is given for staff to obtain or provide medical care for me/my child, or to transport me/my child to a medical facility. I further authorize staff or medical personnel to render such treatment they consider necessary for me/ my child’s health and I agree to pay all costs associated with that care and transportation. I have read and understand this application and the information I have provided is, to the best of my knowledge, correct and complete.
Applicant's Signature

Clear
Date

MonthDayYear
Date
Signature of Parent or Guardian (if applicant is under 18 years).

Clear
Date

MonthDayYear
Date
Should be Empty:

J.U.M.P.’s Adventure IRL!

Insurance Coverage

Signature Required