Ladies Hoop 2 Youth Clinic – Registration Form
Welcome message explaining the clinic is a community-centered program by Heavy Hearted Convos to empower young people through sports, mentorship, and meaningful conversation; registration supports participant safety, program planning, and organizational grant reporting.
Participant Information
Participant Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Age
*
Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
School Name
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Information
Emergency Contact Name
*
Relationship to Participant
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Demographic Information
The following information is collected voluntarily to support grant reporting, program development, and community impact data; responses help secure funding and resources to keep programs free or low-cost for families.
Race / Ethnicity
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino/Latina/Latinx
Middle Eastern or North African (MENA)
Native Hawaiian or Other Pacific Islander
White or Caucasian
Two or More Races / Multiracial
Prefer not to say
Other
Gender Identity
Please Select
Girl / Young Woman
Boy / Young Man
Non-Binary
Gender Fluid
Prefer not to say
Other
Medical & Safety Information
Allergies or Medical Conditions
*
Authorized Pickup Person(s)
Waiver, Liability Release & Media Consent
Waiver, Liability Release & Media Consent
Type your full name to confirm you have read and agree to the Waiver, Liability Release, and Media Consent Agreement above.
*
Today's Date
*
-
Month
-
Day
Year
Date
If you do NOT consent to media/photo/video use of your child, please note that here.
Register
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