Youth Registration

Youth First Name *

Youth Last Name *

Date of Birth *

Ethnicity *

WhiteAfrican AmericanHispanicAsianOther

Street Address *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country *
—Please choose an option—United StatesOther

Attending School *

Grade *

Youth Phone *

Youth Email, if available

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email *

Parent/Guardian Phone *

Relationship to the above-named youth *

MotherFatherGrandparentAuntUncleOther

Street Address *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country *
—Please choose an option—United StatesOther

Emergency Contact First Name *

Emergency Contact Last Name *

Relationship to Youth *

Emergency Contact Phone *

Does youth have any physical problems or limitations? *

YesNo

If yes, please list physical problems or limitations

Does youth have any known allergies? *

YesNo

If yes, please list allergies

Is the youth currently taking any medications staff should be aware of? *

YesNo

If yes, please list medications

I give consent for youth to participate in The Young Kings Movement program, and I agree to follow all program guidelines/rules. *

YesNo

I give permission for youth to be identified as a Young Kings Movement participant and for information to be shared with youth's teachers, counselors and administrators as necessary to support the ongoing needs of my youth. *

YesNo

I give The Young Kings Movement staff/volunteers permission to transport my youth to and from activities by personal, private, or public transportation. *

YesNo

I give The Young Kings Movement staff permission to seek medical attention in the event of an emergency if I cannot be reached. *

YesNo

I give permission for youth's image, including photos, videos, and voice recordings, to be used in Young Kings Movement promotional material, website, and media to support the mission of the program. *

YesNo

I release The Young Kings Movement program from all liability of injury, death, or damages to me, my youth, family estate, heirs, or assigns that may occur as a result of participation in this program and hold harmless any mentor, staff, or representative of any injury, physical or emotional, other than where negligence has been determined. *

YesNo

By signing below, I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions.

Type Full Name Below *

Date