HYMS & HYLS Love and Money Tour Registration Form

HYMS & HYLS Love and Money Tour Registration Form

Please fill out your details to register for the event.
Student Details
Full Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School
Student Birthdate

MonthDayYear
Student Grade
Student Age
Parent/Guardian Information
Parent/Guardian Full Name
Parent/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Email Address
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student
Would you like to participate in the parent workshop?
Name of emergency contact if parent/guardian cannot be reached
Emergency contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact relationship
Authorized pickup person 1
Authorized pickup person 2
Authorized pickup person 3
Emergency & Medical Information
Allergies
Write NA if none
Medical Conditions
Write NA if none
Insurance Provider
Permission to administer basic first aid
Program Questions
Why does the student want to attend the program?
What do they hope to gain from the program?
Strengths and interests
Anything staff should know to support the student
Behavior & Screening
Has the student had any recent conflicts with another participant who may attend?
Are there any concerns that could affect group safety or participation?
Is there anything we should know to help ensure a successful experience?
Consent / Acknowledgements
I understand inappropriate behavior may result in removal
I understand media may be captured during the program
I certify the information above is accurate.
I understand participation expectations
Do you have any special requirements or comments?
Should be Empty:

HYMS & HYLS Love and Money Tour Registration Form

Student Details

Parent/Guardian Information

Emergency & Medical Information

Program Questions

Behavior & Screening

Consent / Acknowledgements