Latino Youth Leadership Club Application

Latino Youth Leadership Club Application
Your Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Emergency Contacts*
Gender*
Birthdate*

MonthDayYear
Date
School Name*
Grade*
Are you of Hispanic Heritage?*

YesNo
Race/Ethnicity*
What program/s are you interested in?*

Club MemberSTEM (Southside Robotics Club)TutoringVolunteering
What are your goals for joining the club?*
What are you wanting to get out of this program? ie. better grades, new friends, volunteer hours
What do you like to do for fun?*
If we took a trip, where would you want to go?*
Additional comments
allergies, accommodations, etc.
Authorization and Release

I, the undersigned parent/guardian, grant permission to the LCDA Latino Club for the use of my child's image in various media formats, including but not limited to online, news, and print

I, the undersigned parent/guardian, grant permission for my child to participate in group text communication related to The LCDA Latino Club
- I understand this consent is valid until revoked in writing by the parent/guardian.
- I release the Latino Community Development Agency (LCDA) from all liability and obligations from any claim for injury, illnesses, claims, or demands.
- I understand that I have the right to revoke this consent at any time by providing written notice to lcdaclub@latinoagencyokc.org
- I understand that my child will not receive any monetary compensation.
- I/We, the undersigned, hereby agree that we have read this agreement and are bound by it.
Date*

MonthDayYear
Date
Student Signature*

Powered by Jotform SignClear
Parent/Guardian Signature*

Powered by Jotform SignClear
Should be Empty: