CYOP Participant Enrollment & Intake Form.

CYOP Participant Enrollment & Intake Form.
Enroll as a student or adult participant in the Competitive Youth of Polynesia (CYOP) program. Please complete all applicable sections.
Are you under 18 years old?*

YesNo
Participant Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Grade (if applicable)
School / University
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Program Interests (check all that apply)*

Academic EnrichmentCultural EducationLeadership DevelopmentAthletics / Sports
Does the participant have any allergies or medical conditions?*

NoYes (please describe below)
If yes, please describe the allergies or medical conditions
Permission to administer basic first aid if needed*

YesNo
How will the participant go home after program sessions?*

Parent/Guardian PickupSchool BusWalkOther
Parent/Guardian Full Name*

First NameLast Name
Relationship to Student*
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email Address*
example@example.com
Preferred Method of Contact*

CallTextEmail
Parent/Guardian Consent: I give permission for my child to participate in CYOP programs and activities, authorize emergency medical treatment if necessary, and acknowledge the information provided.*

I give permission for my child to participate in CYOP programsI give permission for emergency medical treatment if neededI give permission for photo/video/media use of my child (optional)
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Adult Participant Phone Number*
Please enter a valid phone number.
Adult Participant Email Address*
example@example.com
Adult Consent: I confirm that I am 18 years of age or older, voluntarily agree to participate in CYOP programs, authorize emergency medical treatment if necessary, and acknowledge the information provided.*

I am 18 years of age or olderI agree to participate in CYOP programsI give permission for emergency medical treatment if neededI give permission for photo/video/media use (optional)
Participant Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

CYOP Participant Enrollment & Intake Form.

Enroll as a student or adult participant in the Competitive Youth of Polynesia (CYOP) program. Please complete all applicable sections.