Young Keepers of the Culture Participant Form
Child's Full Name:
*
Nickname (if applicable):
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Gender
Male
Female
School Name:
*
Current Grade:
*
T-Shirt Size:
*
Cultural Affiliation
Does your child have any cultural affiliations?
*
Yes
No
If yes, please list tribe, group, organization, or affiliation below:
Back
Next
Parent/Guardian Information
Parent/Guardian Name:
*
Relationship to Child:
*
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
Format: (000) 000-0000.
Relationship to Child:
*
Medical & Safety Information
Does your child have any allergies?
*
Yes
No
If yes, please explain:
Does your child have any medical conditions we should be aware of?
*
Yes
No
If yes, please explain:
*
Is your child currently taking any medications?
*
Yes
No
If yes, please explain:
*
Back
Next
Photo & Media Release
I give permission for my child to be photographed and/or recorded during Young Keepers of the Culture programming, events, workshops, performances, and activities. I understand that photos and videos may be used for promotional materials, social media, grant reporting, newsletters, websites, and other organizational purposes by Feed the Second Line.
*
Yes
No
Participation Agreement
I understand that Young Keepers of the Culture is a cultural and leadership development program under Feed the Second Line. I understand that respectful behavior, participation, and following program guidelines are expected from all participants and families.
Parent/Guardian Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: