Clone of B.L.O.C.S.C Youth Registration & Waiver Form

Proof Civic Network Youth Registration & Waiver Form

Building Leaders On Community and Social Change
Participant Information
Participant Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
School Name
Grade Level
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact
Program Interests
Neighborhood / Community
What issues does your community face?
Previous Civic / Community Involvement
What Change Do You Want to Create?
Leadership / Volunteer Interests

Other
Other Interests
Health & Medical Information
Allergies
Medical Conditions
Medications
Insurance Provider
Physician Name and Number
Confirmation of Physical Ability to Participate

I confirm the participant is physically able to participate
Additional Medical Notes
Communication Opt-Ins
Text message updates from Be The Proof Foundation and Proof Civic Network
Email updates, program announcements, and community opportunities
Signatures
Parent/Guardian Digital Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant Signature
Staff Use Only
Security & Submission
Electronic Signature
Consent to submit this form
Should be Empty:

Proof Civic Network Youth Registration & Waiver Form

Participant Information

Parent/Guardian Information

Program Interests

Health & Medical Information

Communication Opt-Ins

Signatures

Security & Submission