Legacy Sign Up (Community Form)

LEGACY OF LEGENDS CDC

Please provide the most accurate information possible for our newsletter.
Adult (Parent/Guardian) Information
First Name | Nombre de Pila*
Last Name | Apellido*
Date of Birth | Cumpleaños *

MonthDayYear
Date
Gender | Género
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address | Dirección de Casa
Gender | Género
Zip Code | Código Postal
Email Address | Correo Electrónico*
example@example.com
Best Contact Number | Número de Contacto*
Would you like to receive text message updates from Legacy of Legends CDC?*

Yes, I agree to receive occasional SMS updates about events, resources, and reminders. Message and data rates may apply. You can opt out at any time.No, not at this time.
PARENTS: Household Income (Used to determine if any additional services can be provided) PADRES: Ingresos del hogar (se utilizan para determinar si se pueden proporcionar servicios adicionales)
Add Youth/Children | Agregar Jóvenes/Niños

Add your child's name and date of birth
CHILD 1
Name | Nombre

First NameMiddle NameLast Name
Child's Date of Birth | Fecha de Nacimiento del Niño

MonthDayYear
Date
Gender | Género
School Attending | Asistencia a la Escuela
CHILD 2
Name | Nombre

First NameMiddle NameLast Name
Child's Date of Birth | Fecha de Nacimiento del Niño

MonthDayYear
Date
Gender | Género
School Attending | Asistencia a la Escuela
CHILD 3
Name

First NameMiddle NameLast Name
Child's Date of Birth | Fecha de Nacimiento del Niño

MonthDayYear
Date
Gender | Género
School Attending | Asistencia a la Escuela
CHILD 4
Name

First NameMiddle NameLast Name
Child's Date of Birth | Fecha de Nacimiento del Niño

MonthDayYear
Date
Gender | Género
School Attending | Asistencia a la Escuela
What are your primary goals or needs at this time? (Please select all that apply)

Employment AssistanceEducational SupportHousing/Rental/Utility AssistanceFinancial AssistanceHealth and Wellness ServicesFamily & Childcare ServicesLegal AidAfterschool Programs
ABOUT US

Legacy of Legends CDC is a 501c3 organization that is committed to developing trauma informed and resilient communities that focuses on preventing adverse childhood experiences (ACEs) and building vision-based communities through performing arts, leadership, and entrepreneurship. LLCDC provides guidance, mentoring, conflict resolution, community/ civic engagement and education on ACEs (adverse childhood experiences) and Wrap Around services with a goal of Legacy Success Coaches to assist students and families to become resilient and goal oriented. Our goals are to understand your concerns, identify support, and help build Well-Being.
For Youth: Please indicate your child's interest in the following programs offered by Legacy of Legends CDC. Check all that apply:

Youth In Entrepreneurship: This program designed to teach young individuals the fundamentals of starting and running a business. (Some certifications included)Teen Driver's Education: This program provides comprehensive driver's education courses for teenagers to prepare them for safe driving.Frayser Dance Project: This program provides Ballet & Jazz dance classes and performance opportunities for youth interested in developing their dance skills.Fall and/or Spring Break Camp: This provides engaging and educational activities for students during the break period.Summer Success Zone: Our summer program focused on academic enrichment, personal development, and fun!Other: Are there any other opportunities you would like to see presented?
School Name
Grade Level
Please upload a photo/selfie for your Success Zone ID CARD. (PNG or JPG)
File Upload

Cancelof
I hereby consent to the use of my photograph, likeness, and any video or audio recordings made of me by Legacy of Legends CDC for the following purposes:

1. Media Release: I grant permission for Legacy of Legends to use my photograph, likeness, and any video or audio recordings of me in any and all of its publications, including but not limited to, websites, social media, brochures, flyers, posters, presentations, and any other promotional materials, without payment or any other consideration.

2. Wraparound Services: I understand that Legacy of Legends CDC provides wraparoundservices aimed at supporting individuals and families in various aspects of their lives.I consent to participate in these wraparound services, which may include case management, afterschool activities, advocacy, coordination with other service providers, and support in achieving personal goals.

3. Mental Health & Pediatric Services: I understand that Legacy of Legends CDC may provide mental health services, including counseling and therapy. I consent to participate in these services and understand that my participation may involve the disclosure of personal and sensitive information. I understand that all information disclosed during sessions will be kept confidential, except in cases where disclosure is required by law or where there is a risk of harm to myself or others. Any medical information obtained during these checkups will be handled in accordance with HIPAA regulations and the clinic's privacy policy

4. Transportation Services: I, the undersigned parent/guardian of the applicant, hereby give consent for "Legacy of Legends CDC" to provide transportation for my child to and from program activities, events, and other related outings. I understand that all reasonable safety precautions will be taken by the organization and its staff, but I acknowledge that there are inherent risks associated with transportation. I agree not to hold Legacy of Legends CDC, its staff, or volunteers liable for any incidents that may occur during transportation.

I understand that I have the right to refuse to participate in any media-related activities, wraparound services, or mental health services provided by LLCDC, and that my decision to refuse will not affect my eligibility to receive other services offered by the LLCDC.
Date*

MonthDayYear
Date
Would you like to sign up for our weekly newsletter?*

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LEGACY OF LEGENDS CDC

Adult (Parent/Guardian) Information

Add Youth/Children | Agregar Jóvenes/Niños

CHILD 1

CHILD 2

CHILD 3

CHILD 4

Please upload a photo/selfie for your Success Zone ID CARD. (PNG or JPG)