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
2 digit month, 2 digit day, 4 digit 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.
Format: (000) 000-0000.
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
*
How did you hear about BBJF?
*
Please Select
Family or Friend
School
Social Media
Internet Search
Community Event
Community Partner
Current BBJF Family
Other
If other let us know how you found us.
Occupation
Place of Employment
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
Relationship to Child
Authorized Pick-Up Person
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
Physician Address
Hospital Name
City
Other Provider Type
Provider Name
Provider Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit year
Date
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