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ANEW BAM Youth Registration
Student Registration
Student Name *
Your answer
School *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Age *
Required
Grade for fall 2018 *
Required
Gender *
Email Address
Your answer
Home Address
Your answer
Parent Name *
Your answer
Phone Number *
Your answer
Diet Restrictions?
If 'YES', List Restrictions Below
Your answer
Health conditions
Your answer
Photo permission *
Do you grant ANEW BAM permission to use your child’s picture/video in any promotional literature that may be required?
Field Trip *
I give permission for my child to participate and/or be transported by ANEW BAM to special events and field trips. I understand that I will be notified about special events (field trips) prior to the date.
Emergency Contact *
Please provide the contact information for a parent/guardian who can be contacted in case of an emergency if you are unavailable.
Your answer
How will your child get home from programing? *
Pick Up Authorization
List the name(s) If for any reason your child would need to be picked up from the program by someone other than a parent/guardian.
Your answer
Bus stop location
Your answer
Bus stop drop off time
Time
:
Mental/Emotional Health Concerns
In order to best serve all students, please be truthful and clear about any academic or behavior concerns that we should be aware of.
Are there an mental health issues we should be aware of? *
What are the mental/emotional health concerns? Who has these concerns?
Your answer
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