* - Required field.
Youth Information
Inactive
*First name
Middle name
Nick name/Other name
*Last name
Phone number (ie. (970)555-5555)
Email
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip code
Check here if physical address is the same as mailing address.
Physical Address 1
Physical Address 2
Physical City
Physical State
Physical County
Physical Zip code
Student ID number
Date of birth
Place of birth
Are you currently living with your parents? Yes No
Gender
Ethnicity
# of siblings in household
Total # in household (including you)
TANF eligible Yes No
Does your family qualify for free or reduced lunch at your school? Yes No
Primary language at home
School
School Year
Grade
Interests
Special academic recognition (awards, honor roll)
Please list.
Disabilities Yes No
Learning disabilities Yes No
Please describe:
Health and/or Physical challenges Yes No
Please describe:
Allergies Yes No
Please describe:
Medications Yes No
Please list:
Psychological/Mental health issues Yes No
Please describe:
Parent/Guardian Information
First name
Last name
Relationship
If Other:
Home phone
Workplace or Employer
Work phone ext.
Cell phone
Email address
Emergency Contact Information
Emergency contact name
Emergency contact relationship
Emergency contact phone
 
Please list those adults to whom your child may be released. We will only release your child to an individual listed in this area.
How will your child or children get home from our program?
School Bus Parent/Guardian Pick up
Walk
Physician name
Physician phone
Do you participate in any of the following programs?
SOS Outreach Meet the Wilderness
The Literacy Project Buddy Mentors
Small Champions WECMRD
Gore Range Natural Science School Habitat for Humanity
Youth Leaders Council Summer Quest
Celebrate the Beat Other Recreation districts
Copa Edwards Vail Valley Soccer Club
Medical Emergency Policy
In the event that I cannot be reached in an emergency, I agree to accept any and all determinations of need for medical assistance and/or administration of medical attention deemed necessary by The Youth Foundation representatives. I hereby give permission to the medical personnel selected by The Youth Foundation representatives to secure any and all medical, hospitalization, dental, and/or surgical treatment. In event that such medical attention is needed from a healthcare provider, all costs shall be the responsibility of the parent or guardian.
  Yes No
Media Release
I hereby give The Youth Foundation and participating agencies permission to use film, video tape and/or photographs of the above mentioned minor for lawful promotional or informational purposes.
  Yes No