Emergency Contact Information
Please fill out the form below in order for your child to participate in Youth Connection programming for 2017-2018 school year including RAD, DEN and Homework Clubs.
Student First Name
Your answer
Student Last Name
Your answer
Student Grade (2017-18 school year)
Homeroom Teacher (if known, otherwise type:TBD)
Your answer
Youth Connection drop-in programming my child may attend during the school year. Check all that apply:
Home (Primary) Phone
Your answer
Parent 1 First Name
Your answer
Parent 1 Last Name
Your answer
Parent 1 Cell Phone
Your answer
Parent 1 Email
Your answer
Parent 2 First Name
Your answer
Parent 2 Last Name
Your answer
Parent 2 Cell Phone
Your answer
Parent 2 Email
Your answer
Emergency Contact 1
Please provide a contact other than Parent 1 and Parent 2 who can be reached in the event of an emergency.
Your answer
Emergency Contact 1 Phone
Your answer
Emergency Contact 2
Your answer
Emergency Contact 2 Phone
Your answer
Allergies?? If none, type NONE
Your answer
Does your child carry an EpiPen?
Medications?? If none, type NONE
Your answer
Does your child have an IEP (Individualized Education Plan)?
Does your child have a Behavior Plan?
We want your child's experience in Youth Connection to be both positive and supportive. If there is any additional information you would like to share with YC about your child, please use the space below. Use this space to indicate whether or not your child may need some additional supports and what those supports are. If none, type NONE.
Your answer
I have read and understand the Youth Connection sign-in/sign-out procedures, behavior policy, and other general information located here: http://wp.me/P40RkL-ry.
Required
I authorize Youth Connection to disclose/obtain information from District 37 or District 39 Educational teams about my child for the express purpose of developing appropriate program supports for RAD, DEN and/or Homework Club. This release is valid for the entirety of the 2017-18 school year. I understand that I can revoke this authorization at any time in writing, and directed to Youth Connection Program Director.
Should your child require any specific program supports to ensure their success in YC, please indicate your agreement to the above statement by typing your name in the space below. You will also need to fill out a D39 Information located here: http://bit.ly/2o5I9MT.
Your answer
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