Nah'Zia's Corner Safe Space Club Intake & Registration
A warm child and youth intake form for Safe Space Club registration and support planning.
Child Information
Child's Full Name
*
First Name
Middle Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Grade
School
Parent / Guardian Info
Parent / Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Call
Text
Email
Emergency Contact
Emergency Contact Name
*
Relationship to Child
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health & Safety
Allergies
Medical conditions to be aware of
Medications currently being taken
Additional safety information
About Your Child
What are your child’s interests or hobbies?
What are your child’s strengths?
Which best describes your child’s personality?
*
Shy
Outgoing
A mix
Has your child experienced bullying?
Yes
No
Prefer not to say
What support does your child need?
Confidence
Bullying
Social skills
Emotional regulation
Other
Program Interest
Why are you interested in the Safe Space Club?
*
What would you like your child to gain from the program?
*
Availability
What days and times work best after school?
*
Will you be able to pick your child up on time?
*
Yes
No
Permissions
Permission for your child to participate
*
Yes
No
Permission to use photos and videos for Nah’Zia’s Corner
*
Yes
No
Understanding that this is not a licensed therapy service
*
Yes
No
Submit
Should be Empty: