Embracing Legacy Student Application
2017-2018 Student Program Application
Embracing Legacy
Application Date *
MM
/
DD
/
YYYY
New or Returning Youth? *
Student Demographics
Youth Name (Last, First) *
Your answer
Date of Birth - Youth *
Use xx/xx/xxxx format
Your answer
Youth Age (Age 2 - 17) *
*Must be full potty trained.
Your answer
Gender - Youth *
Ethnicity - Youth (Optional)
Please note that this information is optional and is being collected for research and grant purposes only.
Address - Youth *
Your answer
City - Youth *
Your answer
State - Youth *
Example: FL
Your answer
Zip - Youth *
5 digit Zip codes only
Your answer
Home Phone Number - Youth
Use format: xxx-xxx-xxxx
Your answer
Mobile Number - Youth
Use format: xxx-xxx-xxxx
Your answer
School Name (Include Pre, ELEM, MS or HS) *
Your answer
School T ype *
Grade *
Program Information
Program Selection *
Choose all that your youth will participate in
Required
If Tutoring was selected, which subject?
Your answer
Primary Program
If youth is participating more than one entity, which is primary?
Parent/Guardian Information
Custodial Parent/Legal Guardian Information - Mother
Name - Mother *
If mother is not the custodial parent or guardian, please enter N/A
Your answer
Cell Phone Number - Mother
Use format: xxx-xxx-xxxx
Your answer
Home Phone Number - Mother
Use format: xxx-xxx-xxxx
Your answer
Work Phone Number - Mother
Use format: xxx-xxx-xxxx
Your answer
Email - Mother
Your answer
Custodial Parental/Legal Guardian Information - Father
Name - Father *
If father is not the custodial parent or guardian, please enter N/A
Your answer
Mobile Phone Number - Father
Use Format: xxx-xxx-xxxx
Your answer
Home Phone Number - Father
Use Format: xxx-xxx-xxxx
Your answer
Work Phone Number - Father
Use Format: xxx-xxx-xxxx
Your answer
Email - Father
Your answer
Custodial Information
Are there any custody suits or situations the Program should be made aware of? *
If yes, documentation is required.
Is the youth under protective services *
If yes, documentation is required.
Emergency Contact Information (Other than Custodial Parent/Legal Guardian)
In case Custodial Parent/Legal Guardian cannot be reached, please provide the following information:
1st Emergency Contact - Name *
Your answer
Relationship to Youth - 1st Emergency Contact *
Your answer
Phone Number - 1st Emergency Contact *
Use format: xxx-xxx-xxxx
Your answer
2nd Emergency Contact - Name *
Your answer
Relationship to Youth - 2nd Emergency Contact *
Your answer
Phone Number - 2nd Emergency Contact *
Use format: xxx-xxx-xxxx
Your answer
Physician Name *
Your answer
Physician Address (Full Address) *
Your answer
Physician Phone Number *
Your answer
Health Insurance Carrier
Your answer
Health Insurance Policy Number *
Your answer
Please list any special needs, allergies, health or physical conditions that the youth may have. *
If none, please list N/A
Your answer
Custodial Parent Authorization Information
Please list all persons that you authorize to transport and sign your child in and out of rehearsals/performances. At lease ONE authorized person is required:

NOTE: Photo identification is required at all times. Youth will not be released to any person not authorized to Sign them In/Out of rehearsals or performances. Custodial Parent/Legal Guardian will need to contact the program to authorize anyone not listed above.

Authorized Person #1 *
Required Format: Name/Relationship/Phone Number Example: xxx-xxx-xxxx
Your answer
Authorized Person #2
Name/Relationship/Phone Number
Your answer
Authorized Person #3
Name/Relationship/Phone Number; if none, N/A
Your answer
Student Program Transfers
If your child participates in more than one Embracing Legacy program on the same day, please indicate whether you authorize Embracing Legacy Volunteer staff to "transfer" him or her from one program to the other: *
*If you choose NO, please note that you will have to be present to sign your child out of one program and into the next program.
Submission
Name of person completing this form *
Your answer
Relationship to youth *
Your answer
By checking the box below, I am authorizing my youth to participate in Embracing Legacy Programs. I am certifying that all information submitted is truthful and accurate to my knowledge. *
Required
By providing my email address, I am requesting confirmation of application submission.
Your answer
Submit
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