Aunty House - Participant Application

Participant Application

To be completed by Parent or Legal Guardian
Child's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Male, Female, etc.
Guardian's Name

First NameLast Name
Relationship to Child
Mother, father, grandparent, etc.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many people live in your household? Please include their names and relationship to the child.
What is the primary language spoken at home?
English, Spanish, Mandarin, etc.
Does your child have any siblings? If yes, please provide their names and ages:
What are your child's strengths and interests?
Are there any challenges or concerns regarding your child's development or behavior that you would like us to be aware of?
What role does faith play in your child's life?
How would you like us to incorporate faith-based values into the activities we provide at Aunty House for your child?
Does your child have health insurance?
Does your child have any allergies? If yes, please list them:
Is your child currently taking any medications? If yes, please provide the names and dosages:
What is the name of your child's current school? List the grade level and school address.
Is your child willing to participate in activities offered by Aunty House?
What times are best for your child to attend activities?
Are there any limitations or restrictions we should be aware of regarding your child's participation?
Emergency Contact

First NameLast Name
Relationship to Child
Mother, father, grandparent, etc.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything else you would like us to know about your child or your family?
Do you have any questions or concerns about the activities we provide at Aunty House?
Do you consent to your child receiving activities from Aunty House?
Date

MonthDayYear
Date
Parent Signature
Should be Empty: