Beyond Walls Registration 2021
Please complete these Youth Participant Registration Forms in order to participate in programming with Beyond Walls for School Year 2021/2022. If you have any questions, call or text Academic Director Robin Purman at (651) 366-2829, or email her at rpurman@beyondwallsmn.org.
Email *
Student Name *
School student currently attends *
Student Birthdate *
MM
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DD
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YYYY
Student Gender Identity *
Student Grade *
Primary Address *
Parent/Guardian Name & Relationship to Student *
Parent/Guardian phone number *
Parent Email Address *
Student Cell Phone Number (if applicable) *
Preferred way to communicate *
Required
Emergency Contact 1 (must be different than primary guardian): please provide name, relationship to student and phone number. *
Emergency Contact 2 (must be different than primary guardian): please provide name, relationship to student and phone number. *
Transportation Plan & Permission: for the following three questions, choose only ONE method of transportation. If the method doesn't apply to your student, pick "no" Pick the following means of transportation: Parent/Guardian Pick Up at the U of MN Rec. Center *
Transportation Plan & Permission- Pick the following means of transportation: City Bus/Light Rail/Independent *
Transportation Plan & Permission- Pick the following means of transportation: drop off at designated site *
IF YES TO DROP OFF AT DESIGNATED SITE: Please indicate below your choice. *
Student Health: Does your student have any known allergies? *
Student Health: Does your student use an epi pen? *
Student Health: Does your student experience asthma? *
Student Health: Does your student use an inhaler? *
Student Health: Does your student have a heart condition? *
Student Health: Does your student take heart medication? *
Student Health: Please list any and all medications your child is taking *
Student Health: Does your student have any dietary restrictions? *
Student Health: Please list any other important health/medical information our team should know: *
Demographic Information: the following three questions are optional and confidential. This information is only used as group data requested by certain funding sources. Please indicate the racial/ethnic group/groups the student most closely represents(African American, East African, Latinx, Hmong, Multi-Cultural, European…)
How many people live in your household?
Average total yearly household income:
Clear selection
We want to ensure that your student finds success each year they come back to Beyond Walls. Please have you and your student fill out the following questions: Tell us what you and your student are looking forward to about the school year-academically, socially, family events: *
Tell us what you and your student would like to work on this year- academically, socially, physically *
Please let us know any other information you feel is important for us to know in helping your student both on and off the court (behavior, any changes taking place at home, best learning styles) *
Liability Waiver: Beyond Walls Urban Squash Twin Cities staff, and the participating squash facility shall not be liable for any claims, demands, damages or injuries to the student noted above(1) resulting from his/her participating in Urban Squash Twin Cities practices or (2) in connection with the students use of the club, equipment, or premise where these practices take place. Student noted above and his/her parent/legal guardian shall save Urban Squash Twin Cities, officers, director, employees and agents and the participants club(s) harmless form and indemnify Urban Squash Twin Cities officers, directors ,employees and agents and the participating club(s) against all injury, loss or damage of whatever nature (1) resulting from the student’s participation in Urban Squash Twin Cities practices or (2) in connection with student’s use of the club, equipment, or premise where these practices take place. Please type your signature below *
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