Ana's Place Registration

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Please fill out and submit. If you are able, please print, read, sign, and return both the Medical Authorization/Release of Liability form and Participant and Family Guidelines form found at the following links:

Medical Authorization/Release of Liability

Participant and Family Guidelines

Child's First Name *

Middle Initial

Last Name *

Date of birth *

YYYY

Address *

Child's email address *

Child's cell phone *

May program staff or volunteers contact your child directly? *

Yes

May we add your child to group communications? *

Yes

Gender *

Female

Male

Prefer not to say

Other:

School *

Grade *

6th

7th

8th

Hobbies/Interests *

Parent/Guardian Name *

Parent/Guardian email *

Parent/Guardian Primary Phone *

Can we text your primary phone number? *

Yes

Parent/Guardian Secondary Phone

Can we text your secondary phone number?

Yes

Clear selection

Parent/Guardian Mailing Address *

Second Parent/Guardian Name

Second Parent/Guardian email

Second Parent/Guardian Primary Phone

Can we text your primary phone number?

Yes

Clear selection

Second Parent/Guardian Secondary Phone

Can we text your secondary phone number?

Yes

Clear selection

Second Parent/Guardian Mailing Address

What health-related concerns should the program know about your child, including allergies and special accommodations? (Reporting such conditions will not prevent your child from participating and will be kept confidential.) *

Diabetes

Heart Condition

Epilepsy/Seizures

Convulsions

Emotional Upsets (please explain in the next question)

Asthma - carries inhaler? (please answer in the next question)

Allergies - food or environmental (please explain in the next question)

Allergies to medications (please explain in the next question)

Other:

Required

Explanations for health-related conditions (please write N/A if no explanations required) *

List any medications your child will be bringing or carrying (including aspirin, EpiPen, inhaler, etc...) *

List any activities in which your child should not participate OR any physical restrictions your child may have *

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship to Child *

Internet use may be available during our program. Children will be supervised by a program volunteer.

Please select one of the following choices:

I give permission for my child to access the internet including receiving a wifi password to connect personal devices.

I DO NOT give permission for my child to access the internet.

Required

During the program photographs or video recordings may be made of children doing activities. These might be used in a flyer, brochure and/or our websites for promoting our program. Please select one of the following choices:
*

I give my permission to use my child’s photos/videos in the manner described above.

I DO NOT give my permission to use my child’s photos/videos in the manner described above.

I give permission for the following adult(s) (must be over 18) to pick up my child - please include name, phone number, and relationship to child *

I wish to be notified by text if the previous adult(s) pick up my child *

Yes

I give my child permission to walk home *

Yes

I give my child permission to ride the city bus home on their own *

Yes

I wish to be notified by text if my child walks or rides the city bus home *

Yes

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