VIRTUAL
REGISTRATION FORM
Today's Date
*
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Month
-
Day
Year
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Choose Class(s) *Can participate in both classes.
Visual Arts
Yoga
Child's Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
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Gender
*
Male
Female
Ethnicity (For grant purposes)
*
African American/Black
Asian/Pacific Islander
Caucasian/White
Hispanic/Latino
Middle Eastern
Native American
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
E-mail
Child's Health Insurance Provider
WellCare
Aetna
Anthem
Passport Health
Humana CareSource
UnitedHealthcare
Member Number/ID
Which school does your child attend?
*
Child's T-Shirt Size
*
Please Select
Small
Medium
Large
X-Large
2X-Large
3X-Large
How did you hear about Breathe?
*
Facebook/Social Media
Friend
Internet (i.e. Google)
Past Participant
School
Judge
CDW
Counselor
Other
To help us better serve our students, please check all that apply.
*
ADD/ADHD
Aphasia/Dysphagia
Apraxia/Dyspraxia
Asthma
Auditory Processing
Autism/Aspergers
Cystic Fibrosis
Cerebral Palsy
Developmental Delays
Down Syndrome
Dyslexia
Emotional/Behavior Disorders
Food Allergies
Hearing Impaired
Learning Disabilities
Mental Retardation
Neurological Disabilities
Seizure Disorder
Visual Impairment
None
What is child's current home environment?
*
Both Parents
Foster Care
Group Home
Other Family Member
Multiple Family Home
Single Parent
Other
Does your child receive services from a counselor, court designated worker or child protective services? If yes, please give information as to what services.
*
List Additional Medical Conditions or Concerns:
Has your child ever received counseling?
*
Yes
No
Does your child have a hard time sleeping at night?
*
Yes
No
Does your child have problems with making friends?
*
Yes
No
Did your child exhibit or currently exhibiting any developmental delays?
*
Yes
No
Does your child exhibit problems with self-esteem?
*
Yes
No
Does your child have difficulty respecting personal boundaries?
*
Yes
No
Does your child become anxious or worry frequently?
*
Yes
No
Does your child seem sad or depressed frequently?
*
Yes
No
Has there been a significant change in your child’s appetite (eating more or less)?
*
Yes
No
Has your child displayed a significant change in their sleeping patterns?
*
Yes
No
Has your child exhibited cruelty to animals?
*
Yes
No
Has your child ever exhibited episodes of fire setting?
*
Yes
No
Does your child have difficulty maintaining their hygiene?
*
Yes
No
Has your child exhibited or talked about self-harm behaviors?
*
Yes
No
Has your child exhibited or discussed hurting others?
*
Yes
No
Has your child exhibited any episodes of substance abuse?
*
Yes
No
Is your child exhibiting the following behavioral problems at school?
Defiant
Unable to focus
Impulsive
Not completing assignments
Decrease in grades
Parent/Guardian Name:
*
First Name
Last Name
Parent/Guardian Phone Number
*
Format: (000) 000-0000.
Parent/Guardian Email:E-mail
*
Preferred Method of Contact
Phone Call
Text
Email
No Preference
Release of Liability
I assume all risks associated with participating in Light of Chance’s Breathe Youth Arts Program, including, but not limited to slips, falls, contact with other participants, defects or condition. I grant Light of Chance, Inc. and its affiliate’s permission to release photographs and video that are taken of me during the program or events associated with Light of Chance, Inc. for the purpose of promotions and advertising. I hereby authorize Light of Chance to seek medical treatment for my child in the event of an emergency, including transportation by ambulance to the nearest hospital. I understand that I am solely responsible for any medical expenses including ambulance transportation, which my child may incur for any injuries, including those resulting from on-site injuries or off-site on an approved field trip. I hereby release Light of Chance from any and all claims or causes of action for any injuries sustained by my child at the program. I freely and willingly sign this document.
Signature of Parent or Guardian
*
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