Registration Form

HVL Scholars 📚

@ Providence House
Student Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Grade
*IMPORTANT* Please indicate any Food Allergies
Do you have any Medical, Emergency or Medication necessities?
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Number
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency contact (local)

First NameLast Name
Phone Number
Format: (000) 000-0000.
Tutoring Subject(s)
Please describe students needs for academic support (indicate IEP or 504 plan):
Student Signature

I agree to attend AND to participate in this program to the best of my abilities.
Parent/Guardian Signature

By agreeing to my student's participation in this program, I hereby waiver any liabilities to "Stand Up Youth, LLC". and agree to drop any legal claims or demands for damages against "Stand Up Youth, LLC" and it's properties for injuries, losses, or harm, including those caused by their negligence.
Make a Donation - Pay what you can with Cash app 😊
$StandUpYouth
Should be Empty:

HVL Scholars 📚