Future Next Consent Form
Thank you for your interest in Future Next Enrichment Programs. Please complete the information below in its entirety. Note ONLY Parents and Guardians are permitted to complete consent form. There must be a consent form on file for each student. This form only needs to be completed once for participation in Future Next Programs.

Several of these questions (such as Ethnic Background, Free Lunch Meals, Foster Child etc.) are for statistical data collection purposes to inform Future Next about the types of students we serve. This type of information will not be provided to volunteers or Program Coordinators.

Student First Name
Your answer
Student Last Name
Your answer
Nick Name
Your answer
Is this your first time participating in Future Next programs?
Required
Age
Your answer
Date of Birth
mm/dd/yy
Your answer
Gender
U.S Citizen
Required
Foster Child
Receive FREE or Reduced lunch meals?
Ethnic Background:
School my child attends
Your answer
Grade for SY 2015 - 2016
Your answer
How did you hear about Future Next Programs?
Required
Name of Parent/Guardian #1
Your answer
Gender
Relationship to applicant
Name of Parent/Guardian #2
Your answer
Gender
Relationship to applicant
Home/Mailing Address - Street Name
Your answer
Home/Mailing Address - City
Your answer
Home/Mailing Address - State
Your answer
Home/Mailing Address - Zip
Your answer
Home Phone Number
Your answer
Work Phone Number
Your answer
Neighborhood
Please tell us your community name. Example: Dorchester, Lancaster
Your answer
Cell Phone Number
Program information will be sent to this email
Your answer
Email address
Program information will be sent to this email
Your answer
Best way to contact you
Required
Primary Emergency Contact
(Name, Relation, and Phone)
Your answer
Additional Emergency Contacts
(Name, Relation, and Phone)
Your answer
Please list all persons authorized to drop-off/pick-up your child
Your answer
Health History
Please list any medications your child requires
FNC will not administer medication during the program
Your answer
Please check any health conditions that apply to your child
Required
If you checked any health conditions above, please provide any additional details you would like FNC to know.
Your answer
Please list any allergies your child has
(Example: food, or external such as pollen, grass, mold etc..) Please Specify:
Your answer
Please list any behavioral concerns FNC should be aware of:
Your answer
Doctor Name: (Primary Care)
Your answer
Doctor Office Phone Number:
Your answer
Please provide your health insurance information for our records
A copy can be given to the Program Coordinator on the first day of the program.
Health Insurance Policy Name
Your answer
Health Insurance Policy Number
Your answer
I understand that this consent form does NOT register my child for a program. A program registration must be completed for the specific Future Next program.I understand that this program is independently managed and not associated with Charles County Public Schools or Charles County Public Library and NO transportation is provided to and from the program. All information contained in this consent form is true and accurate to the best of my knowledge:
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