Registration and Medical Waiver

Client Intake & Enrollment Form Confidential Registration for Services and Benefits
Full Name First Middle Last
Date of Birth MMDDYYYY

MonthDayYear
Date
Address Street City State
Zip Code
County
Phone Number
Format: (000) 000-0000.
Gender
Social Security Number
Your SSN is protected and will only be used for identity verification purposes.
Are you currently insured
Insurance Provider If applicable
Insurance Policy Number
Additional Demographic Info Are you of Hispanic origin?
Are you of Hispanic origin
Race
How did you hear about us Referral Name or Source
How many people live in your household including yourself
Current Grade Level If youth
Emergency Contact Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Relationship to Participant
Do you have any medical conditions Please list
Do you have any allergies Please list
Religion Optional
Do you receive SNAP benefits
Participation Waiver By signing below, I voluntarily agree to participate (or allow my child to participate) in the ONXCHILL'DREN Youth Entrepreneur Program. I understand the activities may include indoor and outdoor events, workshops, and hands-on business and art-based projects. I acknowledge that I am aware of the risks involved and voluntarily assume them. I agree to hold harmless Official Network and Chill LLC, its staff, and partners from any liability related to injuries or damages incurred during participation.
Media Release - Video & Photos I give permission for Official Network and Chill LLC to record, photograph, and/or videotape me or my child during program activities. These recordings may be used in promotional materials, social media, websites, or future marketing. I understand these images or recordings may be shared publicly and waive any rights to compensation or ownership of such media.
I agree to the terms and conditions and consent to participation.
Acknowledgement & Signature Participant Name: Signature (Parent/Guardian Name (if minor)
Should be Empty:

Client Intake & Enrollment Form Confidential Registration for Services and Benefits

Insurance Policy Number