Program Registration Form

PROGRAM REGISTRATION FORM

This form is designated for individuals who are and/or have youth interested in participating in Urban Family programs.
Youth Name:*

First NameLast Name
Age of Youth:*
School Grade:*
Gender of Youth:*

MaleFemaleTransgenderNon-BinaryPrefer not to AnswerOther
Ethnicity of Youth:*
Birthday of Youth

MonthDayYear
Date
Which school does your Youth currently attend?*

Campbell Hill Elementary SchoolAki Kurose Middle SchoolAsa Mercer Middle SchoolLakeridge Middle SchoolRenton High SchoolTalley High SchoolDimmitt Middle SchoolRainier Beach High School
Parent/ Guardian Name:*

First NameLast Name
Contact Phone Number:*

Area CodePhone Number
Parent/ Guardian Email:*
example@example.com
Home Address:*

Street Address

Apartment/ Unit #

CityState / Province

Postal / Zip Code
Number of People in Household:*
Household Income:*
What is the main reason for enrolling your youth into an Urban Family program?*

Improve health and wellness of the youthDevelop new life skills (example: being on time or having responsibilities)Build routines to improve academic/ school gradesEstablishing relationships in the community and the youth's lifeGaining leadership qualities and self-confidence
Media Release Form
For youth participants that are under the age of 18 years old (minor): *

Parent/ Guardian's First NameParent/ Guardian's Last Name
Parent/ Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Example: 01/01/2023
For those individuals that are 18 years or older:

Participants's First NameParticipant's Last Name
Participant Signature:

Clear
For individuals that are 18 years or older, please signature.
Date Signed:

MonthDayYear
Example: 01/01/2023
Medical Release Form
Please note any special health problems and/or allergies of your child that we must be aware of:*
If your child does not have any health problems and/or allergies, please type NONE.
Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Number:*

Area CodePhone Number
Emergency Contact Relationship to Child:*
2nd Emergency Contact Name:

First NameLast Name
2nd Emergency Contact Number:

Area CodePhone Number
2nd Emergency Contact Relationship to Child:
Authorization for Release of School Records (FERPA)
PURPOSE: As a parent, guardian or student, you have the right to give permission or not give permission for the release of your child’s records with other persons or agencies. This request provides you with the opportunity to approve or not approve such a request unless release of records is allowed under one of the exceptions under the rules implementing the Family Education Rights and Privacy Act, FERPA, (for example, transfer of records from one school district to another).
Student Name:*

First NameLast Name
School District:*
Parent/ Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Example: 01/01/2023
For those individuals that are 18 years or older:

Participants's First NameParticipant's Last Name
Participant Signature:

Clear
For individuals that are 18 years or older, please signature.
Date Signed:

MonthDayYear
Example: 01/01/2023
Field Trip Form

This is a permission slip for Urban Family to invite and transport your child to our Urban Family Program Field Trips. An Urban Family staff member will notify the parent via phone and email about the field trip details at least 2 weeks in advance.
Emergency Contact Number*

Area CodePhone Number
In case of an emergency, how should we communicate?*

CallText
Parent/ Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Example: 01/01/2023
Urban Family Terms and Conditions
By completing and signing this electronic form, I, as the undersigned parent/guardian of the above listed minor (if participant is under the age of 18) acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue the Urban Family Center Association, their directors, officers, employees, managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the programs and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize.
Parent/ Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Example: 01/01/2023
For those individuals that are 18 years or older:

Participants's First NameParticipant's Last Name
Participant Signature:

Clear
For individuals that are 18 years or older, please signature.
Date Signed:

MonthDayYear
Example: 01/01/2023
Should be Empty:

PROGRAM REGISTRATION FORM

Media Release Form

Medical Release Form

Emergency Contact Information

Authorization for Release of School Records (FERPA)

Field Trip Form

Urban Family Terms and Conditions