Big Bro Joe Foundation – Youth Registration Packet
SECTION 1: PROGRAM SELECTION
Select Program for Registration
*
Big Bro Joe Academy
Big Sis Academy
SECTION 2: CHILD’S PRIMARY INFORMATION
Child’s Full Legal Name (Last, First, Middle)
*
Child’s Birthday
*
-
Month
-
Day
Year
Date
Age
City & State of Birth
Shirt Size
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
SECTION 3: EMERGENCY CONTACT
Primary Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
SECTION 4: HOME ADDRESS
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 5: PARENT / GUARDIAN INFORMATION
Parent / Guardian #1
Parent/Guardian Name
*
Relationship to Child
*
Occupation
Place of Employment
Cell Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address
*
example@example.com
Parent / Guardian #2 Optional
Parent/Guardian Name
Relationship to Child
Occupation
Place of Employment
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address
example@example.com
SECTION 6: CHILD PICK-UP AUTHORIZATION
Emergency Contact If Parent Cannot Be Reached
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Authorized Pick-Up Person
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Child
NOT Authorized for Pick-Up
Name
First Name
Last Name
Reason
Relationship to Child
SECTION 7: HEALTH CARE INFORMATION
Health Care Providers
Physician Name
Physician Phone
Please enter a valid phone number.
Physician Address
Hospital Name
City
Other Provider Type
Provider Name
Provider Phone
Please enter a valid phone number.
Health Concerns
Current Medications
Health History
Allergies (include care plan if applicable)
SECTION 8: MEDICAL INSURANCE INFORMATION
Primary Insurance Company
Member / Policy Number
Policy Holder’s Name
Employer’s Name
Consent to Medical Care & Treatment
Consent to Medical Care & Treatment
I give permission that my child may be given first aid or emergency treatment by the founder or a qualified mentor within the Big Bro Joe Foundation. When I cannot be contacted, I authorize and consent to medical, surgical, and hospital care deemed necessary to safeguard my child’s health. I also authorize emergency transportation. I certify this information is true and correct under the laws of the State of Washington.
Parent/Guardian Signature
*
Date
-
Month
-
Day
Year
Date
SECTION 10: MEDIA LIABILITY WAIVER
Consent to Medical Care & Treatment
I grant permission to the Big Bro Joe Foundation to photograph, video record, and use my child’s likeness for educational, promotional, and marketing purposes without compensation.
Media Release & Permission
*
I have read and agree to the Media Release
Parent/Guardian Signature
*
Date
-
Month
-
Day
Year
Date
SECTION 11: PERMISSION FOR PROGRAM TRIPS & TRAVEL
Permission for Program Trips & Local Travel
I give permission for my child to participate in local trips, activities, and supervised travel organized by the Big Bro Joe Foundation throughout the trimester. I understand that all transportation will be coordinated by approved staff or volunteers, and I will be notified in advance of any major outings.
Permission for Program Trips & Local Travel
*
I have read a agree to thePermission for Program Trips & Local Travel
Parent/Guardian Signature
*
Date
-
Month
-
Day
Year
Date
SECTION 12: FINAL ACKNOWLEDGEMENT
FINAL ACKNOWLEDGEMENT
*
I certify all information provided is accurate and complete.
Final Parent/Guardian Signature
*
Date
-
Month
-
Day
Year
Date
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