The L.I.F.E Series High School Application
Thank you for your interest in The L.I.F.E Series; where high school youth attend a weekly Thursday workshop that focuses on leadership, identity, the future, and empowerment. Please fill out the information below and reach out to Dreya Williams if you have any questions 971.207.3489.
Email address *
Student's Full Name *
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Guardians Full Name *
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Student's Cell Phone Number *
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Guardian Phone Number *
Your answer
Student's Gender
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Student's Racial Identity *
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Student's Date of Birth *
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Emergency Contact Name *
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Emergency Contact's Phone Number *
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What is Emergency Contact's relationship to the student? *
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What school does student attend? *
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What grade is the student in (as of Fall 2018)? *
Does the student have an adult support aid (eg: case worker/ PO/ mentor/ etc.)? *
If yes, please describe:
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Does your youth need any disability accommodations? If yes, please explain. *
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What activities are the student interested in? *
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Does the student have any allergies or dietary restrictions? If yes, please describe. If no, type N/A *
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Please indicate any medical conditions that we should be aware of? (Type N/A if no) *
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Names of medications taken by student? Type N/A if none *
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Name and phone number of student's Physician (Type N/A if information unknown): *
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Does the student have medical insurance? *
Name of medical insurance (Type N/A if student is not insured) *
Your answer
Please indicate if you agree with this statement: As parent or guardian, if my youth needs medical attention, I understand every effort will be made to contact me. I hereby give permission to the medical personnel selected by the person in charge of the program to order x-rays, routine tests, treatment, release any records necessary, and to provide or arrange necessary related transportation for the student named on this form. I hereby give permission to the physician selected by the person in charge of the program to hospitalize, secure emergency treatment for, to order injection, anesthesia, and/or surgery for my youth as named on this form. I will assume all financial obligations incurred if not covered by insurance. *
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Thank you for completing this form! We will reach out with more information or if we fill up. Please don't hesitate to reach out if you have any questions.
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