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
PhoneEmailText
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.
YesNo
If yes, please explain medical conditions:
NoneYes
If yes, please list allergies:
YesNo
If yes, list medication names:
YesNo
If yes, provide a brief description:
SECTION 5 - PROGRAM PARTICIPATION CONSENT

Please review and consent to the following statements.
I consent to my child’s participation in Words Are Rich Foundation programs.I understand participation includes coaching, group discussions, and written activities.I understand this program is not therapy or clinical treatment.
I grant permission for photos/videos for educational or promotional use.I do NOT grant permission for photos/videos.
SECTION 6 - ACKNOWLEDGMENT

Please certify and sign below.
YesNo
Parent / Guardian Signature*

Powered by Jotform SignClear
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