Loving Hearts & Praying Hands Inc.
Youth Life Skills Program
Client Intake & Consent to Participate Form
Participant Information
Youth Full Name:
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Home Address:
School Name:
Grade:
Parent / Legal Guardian Information
Parent/Guardian Name:
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact Name:
Emergency Contact Phone:
Format: (000) 000-0000.
Program Participation Areas (check all that apply)
Life Skills Development
Financial Literacy
Youth Entrepreneurship
Career Readiness
Leadership Development
Social & Emotional Learning
Conflict Resolution
Health & Wellness Education
Mentorship & Group Activities
Medical / Special Considerations
Medical conditions, allergies, or special needs:
Consent & Liability Waiver
I, the undersigned parent or legal guardian, give permission for my child to participate in the Youth Life Skills P rogram offered by Loving Hearts & Praying Hands Inc. Participation is voluntary. I agree to release and hold harmle ss Loving Hearts & Praying Hands Inc., its staff, volunteers, and partners from any claims except in cases of gross negligence.
Parent/Guardian Printed Name:
Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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