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SHE PROGRAM MEMBERSHIP APPLICATION
Thank you for your interest in Fine Feather Foundation programming. This application must be completed by a parent or legal guardian on behalf of the minor participant. The information collected will be used to administer the program, maintain accurate records, ensure participant safety, and support program evaluation. The SHE Program will be held at Trexler Middle School in Allentown, Pennsylvania on Thursdays from 2:50 PM to 4:30 PM.
Section 1: Parent / Guardian Information
Parent/Guardian Full name
*
Relationship to Participant
*
Are you the legal parent or court-appointed guardian of the participant?
*
Please Select
Yes
No
E-mail
*
Phone Number
*
Format: (000) 000-0000.
Home Address
*
City
State
Postal / Zip Code
Section 2: Participant (Minor) Information
Participant Full Name
*
Gender
*
Please Select
Male
Female
Prefer not to say
Date of Birth:
*
/
Month
/
Day
Year
Age
*
Ethnicity:
Please Select
Hispanic/Latino
White
Black/African American
Asian
Black/African American & White
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Asian & White
American Indian/Alaskan Native
American Indian/Alaskan Native & Black/African American
Other Multi Racial
School Name
*
Grade (as of current year)
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Section 3: Emergency Contact
Emergency Contact 1
Emergency Contact Name
*
Relationship to Participant
*
Primary Emergency Number
*
Format: (000) 000-0000.
Alternate Emergency Number
Format: (000) 000-0000.
Emergency Contact 2
Emergency Contact Name
*
Relationship to Participant
*
Primary Emergency Number
*
Format: (000) 000-0000.
Alternate Emergency Number
Format: (000) 000-0000.
Section 4: Household Information
Income
*
Please Select
0-$30,000
$31,000-$50,000
$51,000-$60,000
$61,000-$80,000
Housing Status
*
Please Select
Rent
Own
Unhoused
Family Size
*
Please Select
1
2
3
4
5
6
7
8
9
10+
Head of Household
*
Please Select
Female
Male
Other
Single Parent
*
Yes
No
Section 5: Medical Information & Authorization
Does the participant have any medical conditions?
*
Please Select
Yes
No
If yes, please explain
Is the participant currently taking any medications?
*
Please Select
Yes
No
If yes, list type, dosage, and frequency
Does the participant have any allergies?
*
Please Select
Yes
No
If yes, please list
(food, medication, environmental, etc)
Permission for Emergency Medical Treatment
*
Please Select
Yes
No
Parent/Guardian Initials
*
Section 6: Program Participation & Permissions
May participate in all program activities (on-site and off-site)
*
Please Select
Yes
No
Consent to use participant’s image (photos/videos) for program materials
*
Please Select
Yes
Shirt Size
Small
Medium
Large
X-Large
Other
Select Programs of Interest
vocal training
songwriting
performance training
music production and engineering
theater
creative expression
film production
podcasting
DaVinci Workshops
dance/hip hop/jazz/contemporary
arts and crafts-digital illustration
entrepreneurship
peer counseling
counseling
Section 7: Educational Support / IEP Information
Does the participant currently have an Individualized Education Program (IEP) or 504 Plan?
*
Please Select
Yes
No
Prefer not to answer
If yes, would you like to share any information that may help us better support the participant? (Optional)
Are there any learning, behavioral, or developmental needs we should be aware of to ensure a positive experience? (Optional)
Does the participant require any specific accommodations during program activities?
*
Please Select
Yes
No
Use this section to explain required accommodations and let us know if there anything that helps the participant feel comfortable, safe, or successful in group settings? (Optional)
Section 8: Liability Waiver and Assumption of Risk
Parent/Guardian Initials
*
Section 9: CRM & Data Consent
Parent/Guardian Initials
*
Section 10: Certification and Signature
Parent/Guardian Signature
Submit
Should be Empty: