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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