KINDRED Youth Program Application

KINDRED YOUTH PROGRAM APPLICATION

Thank you for your interest in Fine Feather Foundation programming. This application must be completed by a parent or legal guardian on behalf of the minor participant.The information collected will be used to administer the program, maintain accurate records, ensure participant safety, and support program evaluation.
Section 1: Parent / Guardian Information
Parent/Guardian Full name
Relationship to Participant
Are you the legal parent or court-appointed guardian of the participant?
E-mail
Phone Number
Format: (000) 000-0000.
Home Address

CityState

Postal / Zip Code
Section 2: Participant (Minor) Information
Participant Full Name
Gender
Date of Birth:

MonthDayYear
Age
Ethnicity:
School Name
Grade (as of current year)
Section 3: Emergency Contact
Emergency Contact 1
Emergency Contact Name
Relationship to Participant
Primary Emergency Number
Format: (000) 000-0000.
Alternate Emergency Number
Format: (000) 000-0000.
Emergency Contact 2
Emergency Contact Name
Relationship to Participant
Primary Emergency Number
Format: (000) 000-0000.
Alternate Emergency Number
Format: (000) 000-0000.
Section 4: Household Information
Income
Housing Status
Family Size
Head of Household
Single Parent
Section 5: Medical Information & Authorization
Does the participant have any medical conditions?
If yes, please explain
Is the participant currently taking any medications?
If yes, list type, dosage, and frequency
Does the participant have any allergies?
If yes, please list
(food, medication, environmental, etc)
Permission for Emergency Medical Treatment
Parent/Guardian Initials
Section 6: Program Participation & Permissions
May participate in all program activities (on-site and off-site)
Consent to use participant’s image (photos/videos) for program materials
Shirt Size

Other
Programs of Interest
Section 7: Educational Support / IEP Information
Does the participant currently have an Individualized Education Program (IEP) or 504 Plan?
If yes, would you like to share any information that may help us better support the participant? (Optional)
Are there any learning, behavioral, or developmental needs we should be aware of to ensure a positive experience? (Optional)
Does the participant require any specific accommodations during program activities?
Use this section to explain required accommodations and let us know if there anything that helps the participant feel comfortable, safe, or successful in group settings? (Optional)
Section 8: Liability Waiver and Assumption of Risk
Parent/Guardian Initials
Section 9: CRM & Data Consent
Parent/Guardian Initials
Section 10: Certification and Signature
Parent/Guardian Signature
Should be Empty:

KINDRED YOUTH PROGRAM APPLICATION

Section 1: Parent / Guardian Information

Section 2: Participant (Minor) Information

Section 3: Emergency Contact

Section 4: Household Information

Section 5: Medical Information & Authorization

Section 6: Program Participation & Permissions

Section 7: Educational Support / IEP Information

Section 8: Liability Waiver and Assumption of Risk

Section 9: CRM & Data Consent

Section 10: Certification and Signature