Youth Intake & Interest Form

Youth Intake & Interest Form

Please complete all sections to enroll a youth in Words Are Rich Foundation programs. All information is confidential.
SECTION 1 - YOUTH INFORMATION

Please provide information about the youth being enrolled.
Youth's Full Name

First NameLast Name
Nickname (if any)
Birthdate

MonthDayYear
Date
Age
Gender
School / Program / Facility Name
Grade Level
Enrollment Date

MonthDayYear
Date
SECTION 2 - PARENT / GUARDIAN INFORMATION

Parent or guardian contact details.
Parent / Guardian Full Name

First NameLast Name
Relationship to Youth
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Contact
SECTION 3 - EMERGENCY CONTACT (IF DIFFERENT)

Provide an alternate emergency contact if different from above.
Emergency Contact Name

First NameLast Name
Relationship to Youth (Emergency Contact)
Phone Number (Emergency Contact)
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 4 - MEDICAL & SAFETY INFORMATION

Please provide any relevant medical and safety information.
Does the youth have any medical conditions we should be aware of?
If yes, please explain medical conditions:
Allergies (food, medication, environmental)
If yes, please list allergies:
Is the youth currently taking any medications?
If yes, list medication names:
Any behavioral or emotional considerations staff should be aware of?
If yes, provide a brief description:
SECTION 5 - PROGRAM PARTICIPATION CONSENT

Please review and consent to the following statements.
Program Participation Consent (Please check each statement)
Media & Photo Release
SECTION 6 - ACKNOWLEDGMENT

Please certify and sign below.
I certify the information provided is accurate and complete:
Parent / Guardian Signature
How did you hear about Words Are Rich Foundation?
Should be Empty:

Youth Intake & Interest Form

SECTION 1 - YOUTH INFORMATION

SECTION 2 - PARENT / GUARDIAN INFORMATION

SECTION 3 - EMERGENCY CONTACT (IF DIFFERENT)

SECTION 4 - MEDICAL & SAFETY INFORMATION

SECTION 5 - PROGRAM PARTICIPATION CONSENT

SECTION 6 - ACKNOWLEDGMENT