Test Countdown - RCBCCBRAAF

FAMILY APPLICATION

Building Resilience in African American Families

Open Enrollment is from January 1, 2020 – May 3, 2020

Day(s)

Hour(s)

Minute(s)

Second(s)

Parent/Guardian Full Name*
First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship to Youth*
Phone (Number where you can be reached)*
Email Address*
Enter Email Confirm Email
Youth Full Name*
First Last Suffix
Youth Date of Birth (mm/dd/yy)*
MM slash DD slash YYYY
School Currently Attending*
Academic Status*
Grade Level*
School Counselor/Teacher Contact
Ethnicity*
Consent for Participation*
I, the parent or guardian of the above named child, hereby register my youth for participation in the Africentric Rites of Passage Program, and fully agree to the rules and regulations of the Family Health & Support Network, Inc. and do hereby release Family Health & Support Network, Inc. and its directors, representatives, employees, and volunteers from any liability. I, the parent or guardian, releases Family Health & Support Network, Inc. from all responsibilities from injuries of any nature incurred while participating in the program activities.. I understand that my child will be supervised by a trained staff at all times, and that medical insurance is my responsibility.

I have read, understand and I agree to the terms of the Consent for Participation.

Emergency Medical Treatment*

In the event my child becomes ill or sustains an injury while in the care of or under the supervision of the staff, volunteers or other Family Health & Support Network, Inc. representatives, they are given permission to administer first aid for relief. In case of emergency, permission is given to take my child to the nearest appropriate emergency or clinic facility.
Family Doctor Full Name*
First Last
Doctor's Phone Number*
Doctor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Full Name of Emergency Contact*
First Last Suffix
Emergency Contact Phone*
Relationship*
Consent*
I have read, understand and agree to the terms of the Emergency Medical Treatment.