Earn-A-Bike (EAB) Program Online Submission Form
Please complete all areas:
Name of Student: *
Your answer
Child's Date of Birth: *
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Student's Age *
Child's School: *
Child's Grade Level: *
Child's Ethnicity: *
Required
Gender of Student *
Name of Parent(s)/Guardian: *
Your answer
Address: *
Street, City, State, Zip
Your answer
Home Phone Number: *
If no home phone, please use N/A
Your answer
Cell Phone Number: *
If no cell phone, please use N/A
Your answer
Parent Email: *
If no email, please use N/A
Your answer
Name of Emergency Contact: *
Your answer
Relation of Emergency Contact: *
Your answer
Emergency Contact Home Phone Number: *
If no home phone, please use N/A
Your answer
Emergency Contact Cell Phone Number: *
If no cell phone, please use N/A
Your answer
Program Applying for: *
Either as a participant or as a volunteer
Required
What is the date that you are submitting this form? *
MM
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DD
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YYYY
By selecting "Yes I agree", you acknowledge that you have read and understand the policy and procedures of the programs operated by Danbury Youth Services, Inc. As parents/guardians, you understand the responsibilities and will follow the above policy and procedures. *
I give permission for chaperones, administrators, and personnel affiliated with the Danbury Youth Services, Inc. to seek medical attention for my child should he/she become injured. I hereby release chaperones, administrators, and personnel, Danbury Youth Services, Inc and their agencies, commissioners, representatives and employees from all claims with respect to any injury sustained by my child as a result of participation in any program sponsored by Danbury Youth Services, Inc. I authorize Danbury Youth Services to use photographs taken of my child/youth during program time and on field trips. I grant permission for these photographs to be used in promoting the work of Danbury Youth Services. I further authorize permission for the media (newspaper, television, radio) to interview my child and use his/her name if the media publishes an article or conducts an interview concerning any program sponsored by Danbury Youth Services, Inc. I give permission for my child to attend any field trips to: Various local Points of Interest in Danbury, CT.  this will be allowed throughout Danbury Youth Services Programs. These trips will be under the supervision of a Danbury Youth Services staff members.
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