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Intentions’ Registration Form
Our aim is to create intentional programs and events for youth and their community to help them thrive, grow and connect. Our center is grounded in positive youth development. Caregivers play an important role in what we do. We are excited to help you build a strong foundation for your child in their community.


To register your child please fill out the form below. This form serves as registration for all Intentions current and future events.


Please follow Intentionsmn on Facebook for community events and program updates. Please save our program coordinator's email address and phone number for your records.
Yaya 612-567-8672
Ycochran@intentionsmn.org

Intentions Enrichment Center
1500 69th ave N Brooklyn Center Mn 55430
Www.intentionsmn.org
Email: ycochran@intentionsmn.org
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Child’s First Name *
Child’s Last Name *
Child’s Birthday *
MM
/
DD
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YYYY
Current School *
Current grade *
Guardian’s Phone Number *
Home Address *
City, State
Zip Code
What is something your child loves to do? What makes them spark? *
Parent or guardian’s First and Last name *
#1 Emergency Contact name and phone who has permission to pick up your child. *
#2 Emergency Contact name and phone who has permission to pick up your child. *
Is there anyone NOT authorized to pick up your child? *
How is your child getting home after programming. *
Please list any allergies your child has *
By electronically signing my name below, I agree I am the parent or legal guardian of the above named youth. I hereby give consent for my child to participate in Intentions Enrichment Foundation and Self Luv programming. I further agree that Intentions Enrichment Foundation, Self Luv along with employees, agents, officers, contracted agencies and directors of these organizations shall not be liable for any injuries, losses or damages occurring as a result of my child’s participation in Intentions Enrichment Foundation and Self Luv programs.  I hereby assume all risks for the behavior, actions, and safety of myself and/or my minor child(ren) while involved in Intentions programs and activities. I hereby give permission for my child’s photo to be used for Intentions’ Enrichment Foundation and Self Luv promotional purposes across Intentions Enrichment Foundation and Self Luv brands. I hereby give permission for Intentions’ certificated volunteers to transport my child in Intentions’ van. I will not hold Intentions’ staff or volunteers liable for loss of life or accidents while transporting my youth if driver negligence did not occur. *
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