Application for The Urban League of Portland’s Middle School After School Leadership Program (Responses)
Email address *
Is your child a middle school student (as of Fall 2018)? *
How did you hear about this program? *
Your answer
Are you(the person filling out this application) the applicant's/student's legal guardian? *
First name of person completing this application: *
Your answer
Last name of person completing this application: *
Your answer
What is your relationship with the student/applicant? *
Your answer
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Middle Initial *
Your answer
Mailing Address *
Your answer
City *
Your answer
Zipcode *
Your answer
Student's Email Address *
Your answer
Student's Cell Phone Number *
Your answer
Student's Household Phone Number *
Your answer
Student's Gender *
Student's Ethnicity *
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Is the student a refugee? *
Is the student homeless? *
Please select the option that most closely describes the student's current living situation for the past 30 days: *
Guardian's First Name *
Your answer
Guardian's Last Name *
Your answer
What is guardian's relationship with student? *
Your answer
Best Phone Number to Reach Guardian *
Your answer
Additional Number to Reach Guardian *
Your answer
Guardian's E-mail *
Your answer
Number of adults in household? *
Your answer
Number of youth in household? *
Your answer
First Name of Emergency Contact *
Your answer
Last Name of Emergency Contact *
Your answer
Emergency Contact's Phone Number *
Your answer
Emergency Contact's Email *
Your answer
What is Emergency Contact's relationship to the student? *
Your answer
Where does the student attend or plan to attend school? *
Your answer
What grade is the student in (as of Fall 2018)? *
Does the student have an IEP/504 plan? *
Does the student read at grade level? *
Is the student eligible for free or reduced price lunch in his/her school? *
Does the student have an adult support aid (eg: case worker/ PO/ mentor/ etc.)? *
If yes, please describe:
Your answer
Does your youth need any disability accommodations while they're in our space? If yes, please explain. *
Your answer
What activities are the student interested in? *
Your answer
What makes your student special? *
Your answer
Does the student have any allergies or dietary restrictions? If yes, please describe. If no, type N/A *
Your answer
Please indicate any medical conditions that we should be aware of? (Type N/A if no) *
Your answer
Names of medications taken by student? Type N/A if none *
Your answer
Name and phone number of student's Physician (Type N/A if information unknown): *
Your answer
Does the student have medical insurance? *
Name of medical insurance (Type N/A if student is not insured) *
Your answer
Insurance Number/Policy ID (Type N/A if student is not insured) *
Your answer
Primary insured's name (Type N/A if student is not insured) *
Your answer
The Urban League of Portland's Youth Programs do not discriminate against otherwise qualified participants on the basis of disability. Is there any support/accommodations you'd like to request for yourself or your youth that will help them succeed in our program? *Youth with disabilities may need parents to attend the program to assist their youth.* *
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. *
Required
Name of guardian filling out application: *
Your answer
I am a legal guardian of the applicant and I have read, understand, and agree to the Urban League of Portland’s Code of Conduct policy. I understand and agree to the responsibility requiring parents to pick up youth asked to leave Urban League programs due to behavior and/or conduct. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service