Black Youth Count! Future Leaders Collective

Black Youth Count! Future Leaders Collective

Thank you for your interest in joining our after-school program! Please complete the following intake form to help us better understand and support your needs. This information will remain confidential and will only be used for program purposes.
Participants Name:

First NameLast Name
EMAIL:
example@example.com
PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH:

MonthDayYear
Date
AGE:
Gender:
Gender Identity:
Pronouns:
GRADE LEVEL:
SCHOOL NAME:
Parent Contact Information:

First NameLast Name
PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL:
example@example.com
ADDRESS (If Different from Above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student:
Emergency Contact:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student:
HEALTH INFORMATION
Does the participant have any allergies (food, medication, etc.)?
If Yes, please specify:
Does the participant have any medical conditions or special needs we should be aware of?
If Yes, please specify:
Is the participant currently taking any medications?
If Yes, please specify:
PRIMARY CARE PHYSICIAN'S NAME:
PHYSICIAN'S PHONE NUMBER:
Preferred Hospital
PROGRAM INTERESTS & GOALS
What are your primary reasons for joining this program? (Check all that apply):

Other
What goals do you hope to achieve through this program?
Are there any specific topics or activities you would like to see included in the program?
ADDITIONAL INFORMATION
How did you hear about this program?
Is there any other information you would like us to know about the participant?
Parent/Guardian Consent

Please read in entirety, sign and date.
I, the undersigned parent/guardian, give permission for my child First Name* Last Name* , to participate in the "Black Youth Count! Future Leaders Collective" after-school program. I understand that the program involves various activities, and I give consent for my child to participate in all program-related activities. I also authorize the program staff to seek emergency medical treatment for my child if necessary.
Parent/Gaurdian Signature:
Date

MonthDayYear
Date
Participant Consent

Please read in entirety, sign and date.
I, First Name* Last Name* , agree to participate in the "Black Youth Count! Future Leaders Collective" after-school program. I understand the purpose of the program and agree to abide by the program's rules and expectations.
Participant's Signature"
Date

MonthDayYear
Date
Should be Empty:

Black Youth Count! Future Leaders Collective

HEALTH INFORMATION

PROGRAM INTERESTS & GOALS

ADDITIONAL INFORMATION

Parent/Guardian Consent

Participant Consent