Participant's Name
*
First Name
Middle Name
Last Name
Participant's Grade?
*
Participant's Date of Birth?
*
-
Month
-
Day
Year
Participant's Address
*
Street Address
Apt/Unit #
City
State / Province
Postal / Zip Code
Participant's Phone Number
-
Area Code
Phone Number
Participant's Email
example@example.com
Parent's Name
*
First Name
Middle Name
Last Name
Parent's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Phone Number
*
-
Area Code
Phone Number
Parent's Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
-
Area Code
Phone Number
Relationship to Child
Back
Next
How did you hear about this program?
Why do you want to participate in Blueprint for Womanhood?
What activities are you involved in at School?
Is there anything specific you would like to learn or do while you are in the program?
Anything you would like to add?
Back
Next
Parent’s Commitment
I understand that if my child misses three (3) classes she will be dropped from the program.
*
YES
NO
I commit to making sure my child will be dropped off and picked up on time for each class that she attends.
*
YES
NO
Life Paradigms, Inc. (including staff, volunteers and instructors) is not responsible for any injuries that occur while your child is attending the program and/or during bonding times throughout the year (activities, classes, circles, fundraisers and events). I have read, understand and agree to this statement.
*
YES
NO
Does your child have any special needs?
*
YES
NO
IF YES, PLEASE EXPLAIN
Does your child take any medication?
*
YES
NO
IF YES, PLEASE EXPLAIN
Does your child have any concerns you want us to address?
*
YES
NO
IF YES, PLEASE EXPLAIN
Does your child have any allergies (environmental, food, or medication)?
*
YES
NO
IF YES, PLEASE EXPLAIN
Parent's Signature
*
Submit
Should be Empty: