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Pokemon Club Grades 2 and up - 2023 - 2024
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Student's First Name
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Your answer
Student's Last Name
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Your answer
Student's Grade
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Your answer
Student's Teacher's Name
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Your answer
Student's Age
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Your answer
Please list any medical conditions, medications taken and/or any allergies
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Parent(s)/Guardian(s): Name(s) & contact #
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Your answer
Contact Email
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Your answer
Designated pick-up person's name and contact #
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Your answer
Permission to photograph student & use image for various publications, such as TI Sun, HFY Website & Facebook
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Yes
No
Does the Student require a HFY member to walk them to Macsherry Library from the school?
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Yes
No
If the student requires additional assistance during school, the parent or guardian must provide an adult to accompany the student to any Hearts for Youth program.
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No additional assistance
Yes additional assistance - please email name of adult to
heartsforyouth@gmail.com
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