Intake Form

Parent /Guardian

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Community

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Best way to get in touch

Student Information

Student Name

First NameLast Name

Student Age

Student Birthdate

Date

Student Gender

Preferred Name of Student if different

General Information

When you child has free time, they...(check all that apply)

What would you like us to know about your child?

Do you have access to transportation?

Medical Information

Describe any medical issues (write NA if it does not apply)

List any medications

List any allergies

Emergency Contact #1

First NameLast Name

Emergency Contact # 1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact #2

First NameLast Name

Emergency Contact # 2 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

In the unlikely event of an emergency and we are unable to reach either parent/guardian or the Emergency contacts listed above, please indicate your preference below……..

If your child needs to be transported to an area hospital, let us know your preferences below. If you have a specific hospital select "Other" and then give us the name.

Other

If a medical decision needs to be made and we are unable to reach either parent/guardian or the Emergency contacts listed above, please indicate your preference below…

School Information

Which school district are you in?

In order to facilitate the Mentor-Mentee matching process and to enable the LIFT program through DNA Community Center, Plain City, Ohio to match your student with one of our trained and approved adult Mentors, I, (Parent/Guardian) hereby give my permission for Name of School District to share information for (Student Name) with my child's LIFT Mentor and/or DNA Mentoring Coordinator.

Information to share

I further understand that the information collected by LIFT and/or my child’s LIFT Mentor will be kept private and confidential by the Mentor and other representatives of the LIFT Program, and that information shared with my child’s Mentor will be used to guide the work of the Mentor during interactions with my child/student.

WAIVER and RELEASE:
I, as the parent/guardian of the children listed below, execute this Waiver and Release for and on behalf of the minor children named herein. I fully consent to my child(ren)'s participation in the DNA LIFT MENTORING PROGRAM. I hereby take the following action for the named child(ren), myself, my spouse, executors, administrators, heirs, next of kin, successors and assigns: (a) I WAIVE, RELEASE AND DISCHARGE Daily Needs Assistance (hereafter DNA), and their respective directors, officers, employees, representatives, volunteers and agents from any and all claims or liabilities for death, personal injury, illnesses or damages of any kind, which arise out of or relate to my child(ren)'s participation in any way in the Events in this Program, either at DNA or other participating locations; (b) I AGREE NOT TO SUE DNA or any other participating locations for any of the claims or liabilities that I have waived, released or discharged herein; and (c) I AGREE TO INDEMNIFY AND HOLD HARMLESS DNA or any other participation locations from any claims made or liabilities assessed against them as a result of my actions or my child(ren)'s action. I represent that I have legal capacity and authority to act for and on behalf of the child(ren) named herein, and I agree to indemnify and hold harmless the DNA for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the child(ren) in the execution of this Waiver and Release. I agree that this Waiver and Release is intended to be as broad and inclusive as is permitted by the laws of the State of Ohio and that, if any portion is held invalid, it is agreed that the balance shall continue in full force and effect.

I understand that I and/or my child(ren) may be photographed or videotaped while at this program. I consent to the use of these photographs or copies of them in any editorial and/or promotional materials produced and/or published by DNA Parties. Such materials may include published printed materials, video, television or internet publications or other forms of publication. The DNA Parties are interested in protecting my privacy, so neither my name nor the name of my child(ren) will be used in any publication. I will not hold the DNA Parties liable if other people or organizations copy and paste those photographs and use them for unintended purposes.

I read the Waiver and Release section above

Type in Child's Name

Age of Child

Birthdate of Child

Date

Name of Parent/Guardian

Signature of Parent/Guardian

Date

I am a human because 2 + 4 =

D.N.A. Community Center