Far From Fatherless Membership Application

Full name*

First NameLast Name

Gender

Date of Birth:*

Date

Age

E-mail*

example@example.com

Phone Number*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency contact*

First NameLast Name

Phone number*

Grade (January 2024):

Ethnicity:

Income

0-$30,000$31,000-$50,000$51,000-$60,000$61,000-$80,000

Head of Household

FemaleMaleOther

Single Parent

YesNo

Family Size

Rent or Own

RentOwnUnhoused

Permission for Treatment by Doctor/Hospital:

Do you have Health Problems?

If Yes, Please Explain.

Do you take any Medications?

If Yes, Please Explain.

Do you have any Allergies? Please List Below.

Member may participate in all Program activities on or off site:

Member has permission to be used in public relations materials:

Shirt Size

Disclaimer:

I give this member permission to attend and participate in activities sponsored by Fine Feather Foundation Inc. and Far From Fatherless Program of Allentown, Pennsylvania. I hereby release the Fine Feather Foundation and Far From Fatherless Program, its employees, associates, and contributors from liability from any injury or loss incurred by this member while participating. Furthermore, I hereby authorize medical examination and emergency treatment for this member by a qualified licensed physician in the event of an accident. I further understand that the program has an “Open Door” policy, which means that this member may come and go at will. However, we request that you notify us as least two weeks in advance if you wish to withdraw from the program. Further, I give permission for this member’s picture to be used in any Program publication unless member responded no as stated in the above. The Fine Feather Excelsior program is not responsible or liable in any way in the event of harm or injury occurring to the member. It is agreed that the parent or guardian will not hold the program responsible for the welfare or whereabouts of the member. If the Parent or Guardian does file a complaint against the program and/or foundation, the Parent or Guardian agrees to pay for the program’s or foundation’s legal fees.

I give my permission to the Far From Fatherless Program of Allentown, Pennsylvania to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Far From Fatherless Program’s staff, Fine Feather Foundation Inc, funders, and other community stakeholders to evidence program effectiveness and/or program impact on our members.

I understand that the Far From Fatherless Program of Allentown, Pennsylvania may share information about the minor child listed on this application with Fine Feather Foundation and its partners for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to Fine Feather Foundation Inc. may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Far From Fatherless Program for Allentown, Pennsylvania, including data collected via surveys or questionnaires. All information provided to Fine Feather Foundation Inc. will be kept confidential.

My signature indicates that I completely understand the above statement.

Parent/Guardian Signature

FAR FROM FATHERLESS MEMBERSHIP APPLICATION

Income Verification

MEDICAL PERMISSION