Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. health Parent/Guardian with Participant Information Child's Name *FirstLastGender *MaleFemaleNon-binaryPrefer not to sayOtherDate of Birth *School Name / District *Grade Level *Pre-KKindergarten123456789101112Ethnicity/Race *Primary Language Spoken at Home *Parent/Guardian Information Parent/Guardian Name *FirstLastRelationship to Child *Phone *Email *Secondary Contact (Optional)FirstLastSecondary Contact Phone (Optional)Emergency Contact Emergency Contact Name *FirstLastEmergency Contact Phone *Health & Wellbeing Does your child have allergies or medical conditions? *--- Select Choice ---YesNoMedical Conditions/AllergiesIs your child currently receiving mental health or counseling services? *--- Select Choice ---YesNoPrefer not to answerAreas of Concern or Goals for Your Child *Program Cohort Tracking Which Cohort is your child enrolling in? *--- Select Choice ---Cohort 1 [ages 4–6]Cohort 2 [ages 7–10]Cohort 3 [ages 11–13]Cohort 4 [ages 14–18]Have they participated in this program before? *--- Select Choice ---YesNoConsent & Agreements Photo/Media Release *--- Select Choice ---Yes, I give permissionNo, I do not give permissionI grant permission for my child’s photograph, video, or audio recording to be taken during program activities. These images or recordings may be used by Friends and Mentors Inc. and Sabura Youth Programs for educational, promotional, or reporting purposes, including publications, social media, websites, and presentations. I understand that my child’s name will not be publicly disclosed without my consent.Liability Waiver Agreement *I have read and agree to the Liability Waiver (required to participate).I understand that my child will be participating in activities organized by Friends and Mentors Inc. and Sabura Youth Programs. I acknowledge that these activities may involve some level of risk. By signing this form, I release Friends and Mentors Inc. and Sabura Youth Programs, its staff, volunteers, and partners from any liability for injuries, accidents, or losses that may occur during participation, except in cases of gross negligence or willful misconduct. I also agree to follow all program rules and ensure my child does the same.Permission to Share Aggregate Data with Funders *--- Select Choice ---Yes, I give permissionNo, I do not give permissionI understand that Friends and Mentors Inc. and Sabura Youth Program collects information from program participants to evaluate and improve services. By agreeing, I give permission for my child’s data to be included in aggregate (group-level) reports shared with funders and partners. These reports will never include personal identifiers such as names, addresses, or contact information—only combined statistics (e.g., total number of children served, age ranges, demographics).Parent/Guardian Signature * Clear Signature By signing below, I confirm that the information provided is accurate to the best of my knowledge. I acknowledge that I have reviewed and agree to the program’s policies, including consent, waivers, and participation guidelines.Typed Full Name *FirstLastToday's Date *Register
