Parent/Peer Education Series
The summer series is to keep parents informed, and to educate teens who can then share thier accurate information with peers. Teens earn Peer Education community service hours for the time spent learning
Email address *
Participant's Name *
Which education program are you signing up for: *
Date of Birth: *
MM
/
DD
/
YYYY
Address *
School and grade *
Gender
Clear selection
Parent/Legal Guardian Name *
Phone Number: *
Clear selection
Please check here if you do not want your child's photos (without name) published on community sites
Demographics
Race
Clear selection
Ethnicity
Clear selection
Family
Clear selection
Do you need information on reduced fees and scholarships for this program?
Clear selection
Clear selection
Permission and Emergency Medical Information
If your child requires pick up, is there anyone NOT authorized to do so?
Emergency Contact *
Relationship *
Phone Number *
Are there any specific medical conditions we should be aware of? *
If your child requires pick up is there anyone who may NOT pick them up? *
Are there any specific medical conditions we should be aware of? *
In case of emergency, if I cannot be reached I give permission to the attending physician to hospitalize, seek treatment, order injections, anesthesia, or surgery for my child named on this form. Additionally I the undersigned, do hereby waive and hold Granby Youth service Bureau, its employees and agent harmless from any personal or property damage I or my child may incur while participating in this activity, I also understand Granby Youth Services does not provide accident or health insurance. In addition by electronically signing and dating below I am indicating my permission for my child to participate in this Granby YSB program: *
For questions or for more information contact AnneMarie Cox at (860) 844-5355 or email her at ahcox@granby-ct.gov
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