AAYHF STEM

Date/Fecha*

Date

Who referred you/¿Quién lo remitió? *

Name / Nombre*

First name/Primer nombreLast Name/Apellido

Total # of family members in household/ # Total de miembros del hogar*

Household Income (estimate)/ Ingreso del hogar (aproximado)*

Email / correo electrónico*

example@example.com

Phone Number / Número de teléfono*

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

Zip code/Código Postal*

Age/Edad*

Ethnicity/Etnicidad (marque una)*

Race /Raza*

Gender/Género (marque)*

First Child Name/Nombre del primer hijo*

First name/Primer nombreLast Name/Apellido

Program/Programa - Youth*

First Child Age/Edad del primer hijo*

First Child Gender/Género del primer hijo*

First Child Grade/Primer grado para niños

First Child School District/Distrito Escolar del Primer Niño

Second Child Name

First NameLast Name

Program/Programa - Youth 2

Second Child Age / Edad del segundo hijo

Second Child Gender / Sexo del segundo hijo

Second Child Grade / Segundo grado para niños

Second Child School District / Distrito Escolar del Segundo Niño

Third Child Name / Nombre del tercer hijo

First NameLast Name

Program/Programa - Youth 3

Third Child Age / Edad del tercer hijo

Third Child Gender / Sexo del tercer hijo

Third Child Grade / Tercer grado para niños

Third Child School District / Distrito escolar del tercer niño

Fourth Child Name / Nombre del cuarto hijo

First NameLast Name

Program/Programa - Youth 4

Fourth Child Age / Edad del cuarto hijo

Fourth Child Gender / Sexo del cuarto hijo

Fourth Child Grade / Cuarto grado para niños

Fourth Child School District / Distrito Escolar del Cuarto Niño

Fifth Child Name / Nombre del quinto hijo

First NameLast Name

Program/Programa - Youth 5

Fifth Child Age / Edad del quinto hijo

Fifth Child Age Gender / Sexo del quinto hijo

Fifth Child Grade / Quinto grado para niños

Fifth Child School District / Distrito Escolar del Quinto Niño

Sixth Child Name / Nombre del sexto hijo

First NameLast Name

Program/Programa - Youth 6

Sixth Child Age / Edad del sexto hijo

Sixth Child Gender / Sexto sexo del niño

Sixth Child Grade / Sexto grado para niños

Sixth Child School District / Distrito Escolar del Sexto Niño

Program/Programa - Adult

Special Events/ Evento especial:

Best Method of Contact / El mejor método de contacto *

Approve Media Release/ Aprobar el comunicado de prensa*

I certify that I currently receive the indicated income from the following source / Certifico que actualmente recibo los ingresos indicados de la siguiente fuente*

I am self-declaring my identity as proof of identification at this time. / En este momento declaro mi identidad como prueba de identidad*

Additional Comments / Notes / Comentarios adicionales/notas

Final Consent: I am the parent or guardian of minor(s) named above and have legal authority to execute this consent and release. By electronically submitting this consent, I have read and agree to all terms as listed below. I give permission for my child to receive services provided, including but not limited to supportive guidance/counseling, tutoring, enrichment activities, testing, and referrals to other agencies as needed. To transport my child in agency vans and/or staff-operated vehicles to and from in-school and/or our after-school site on special field trips (separately authorized by parent or guardian). I hereby release participating agencies and/or the operator of the vehicle being used from any responsibility and liability for any damage, injury or illness which might occur during, or resulting from, the authorized transporting of my child. I understand and agree that neither the program nor its employees and volunteers are responsible or legally liable for any personal property losses or for any bodily injuries incurred and suffered by the child on any program property or in connection with any program activities. I understand that my child must adhere to all AAYHF rules and regulations to remain in the program. I give permission to the program to make and retain copies of the child's report cards and/or progress reports to better understand the needs of the child. I understand that this consent is voluntary. I understand that the records and information released under this consent will be kept confidential to the extent permitted by law and will be used for the purpose indicated.*

YESNO

African American Youth Harvest Foundation