Participant Application
To be completed by Parent or Legal Guardian
Child's Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male, Female, etc.
Guardian's Name
First Name
Last 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
City
State / 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?
Yes
No
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?
Yes
No
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 Name
Last 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?
Yes
No
Date
-
Month
-
Day
Year
Date
Parent Signature
By signing, you agree to provide accurate information and allow us to contact you for further discussion regarding your child's partiipation.
Submit
Submit
Should be Empty: