Youth Leadership Program Application & Parent Consent

Youth Leadership Program Application & Parent Consent

Apply to participate in A Door of Hope Outreach Inc.'s Youth Leadership Programs. Complete all sections to ensure eligibility and consent.
Participant Information

Please provide the participant's personal details.
Participant Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender (optional)
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Email (if applicable)
example@example.com
School & Community Information

Tell us about your current school and community.
School Currently Attending
Current Grade
Public SchoolPrivate SchoolHomeschoolNot Currently Enrolled
EdgewoodJoppaAbingdonAberdeenBel AirHavre de GraceOther
Zip Code (Community)
Parent/Guardian Information (Required for Ages Under 18)

To be completed by parent/guardian for participants under 18.
Parent/Guardian Name

First NameLast Name
Relationship to Participant
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact (if different) - Name
Emergency Contact (if different) - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Program Participation & Monthly Meetings

Participants are expected to attend monthly meetings and participate in various activities.
I Agree
Mental Health Acknowledgment

This program includes mental health awareness discussions and emotional wellness conversations.
I Understand and Agree
Medical Information

Please provide medical details for the participant.
YesNo
If yes, please explain
Allergies
Current Medications
Yes
Transportation Permission

Some activities may occur off-site.
My child MAY be transported by authorized staff/approved volunteers.My child MAY NOT be transported.
Photo & Media Release

Photos or videos may be used for website, social media, fundraising, and grant reporting.
I Give PermissionI Do NOT Give Permission
Electronic Device & Privacy Policy

To protect confidentiality and ensure a focused environment, please review our policy.
I Understand and Agree
Code of Conduct

Participants are expected to show respect, follow instructions, and maintain appropriate behavior.
I Agree
Liability Waiver

Release of liability for participation in program activities.
I Agree
Signatures

Sign below to confirm your consent and agreement.
Parent/Guardian Printed Name
Parent/Guardian Signature (Required for Ages Under 18)

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Date (Parent/Guardian Signature)

MonthDayYear
Date
Participant Signature (Required for Ages 18–21)

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Date (Participant Signature)

MonthDayYear
Date
A Door of Hope Outreach Inc. | Edgewood, Maryland | 501(c)(3) Nonprofit Organization | “Building Pathways to Stability and Hope”
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Youth Leadership Program Application & Parent Consent

Participant Information

School & Community Information

Parent/Guardian Information (Required for Ages Under 18)

Program Participation & Monthly Meetings

Mental Health Acknowledgment

Medical Information

Transportation Permission

Photo & Media Release

Electronic Device & Privacy Policy

Code of Conduct

Liability Waiver

Signatures