Welcome!
Please take the time to fill out this information so that our staff has all necessary contact and medical information and permissions. Thank you! ~The Hub
Participant's First Name:
Participant's Last Name:
Participant's Preferred Email Address:
Participant's Date of Birth:
-
Month
-
Day
Year
Date
Participant's Preferred Phone Number Type:
Home
Cell
Preferred Phone Number:
Participant's Primary Address Street 1:
Street 2:
City:
State:
Zip Code:
County:
Primary Parent/Guardian's First Name:
Primary Parent/Guardian's Last Name:
Primary Parent/Guardian's Preferred Phone Number Type:
Home
Work
Cell
Primary Parent/Guardian's Preferred Phone Number:
Primary Parent/Guardian's Secondary Phone Number:
Primary Parent/Guardian's Preferred Email Address:
Is primary parent/guardian's address the same as the participant's address?
Yes
No
If the above answer is no, please provide the primary parent/guardian's street address, city, state, zip code, and county:
Emergency Contact
In addition to the parent listed previously we would like to have an additional emergency contact for this participant. It can be another parent or guardian, relative, family friend--anyone with a different phone number than the primary parent contact.
Emergency Contact's First Name:
Emergency Contact's Last Name:
Emergency Contact's Preferred Phone Number:
Emergency Contact's Secondary Phone Number:
Emergency Contact's Relationship to Participant:
Pick Up Authorization
Whom do you authorize to pick up the participant?
Is there anyone WITHOUT authorization to pick up the participant?
Medical Information
Participant's Insurance Company:
Policy Identification Number:
Policy Group Number:
Policy Holder's First Name:
Policy Holder's Last Name:
Are there any allergies, dietary restrictions, or medical/health issues you'd like to share? If so, please describe here:
Any there any over the counter medications you give us permission to give the participant as needed? If so, please list the medications you authorize us to give:
I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. In the event that I cannot be contacted during a medical emergency, I hereby authorize The Hub's staff to give my child first aid when appropriate, and, in an emergency, to arrange medical care for my child from a hospital or other health care provider as may seem necessary or appropriate under the circumstances without further written authorization, including transportation to a medical care facility. I understand that The Hub will have no liability for obtaining such medical care, whether arising from the cost of such care or otherwise, including the consequences of such care. I also waive any claim for the consequences of preexisting undisclosed or unknown conditions of my child.
Yes
Photo and Video Authorization
The Hub/High Rocks maintains a website (www.highrocks.org) and we may post pictures and/or videos of our activities. Pictures and/or videos may also be displayed on social media, flyers/brochures/posters and outside publications such as local newspapers. Because your child’s image may be included in these pictures and/or videos, we must obtain your permission. Participants’ names may be used in publications, but no other personal information will be posted.
Please choose one of the two statements below:
Yes, I give my permission for this participant’s image to be included in photos and/or videos as outlined above.
No, I do not give permission for this participant’s image to be included in photos and/or videos as outlined above.
Participation Authorization
I am the parent/legal guardian of this participant, and I am informed of the activities offered by The Hub, including workshops, tutoring, and special events. I consent for the participant to attend and participate in all activities provided by The Hub.
Yes, I consent.
Information Helpful for Raising Money for High Rocks
Keeping our programs tuition free requires a lot of fundraising and publicity. Often, foundations who support High Rocks request information about the young people and families involved in our program. It would be helpful to us if you would answer the following questions. These questions are optional and your answers will remain anonymous:
Is your household considered to be financially within the federal poverty limit?
Yes
No
I don't know
I do not wish to share
Are the adult members in your household:
Employed
Unemployed
Retired
On disability
Combination of the above
I do not wish to share
Parent/Guardian Education Completed:
Some High School
High School Diploma
Certificate Program
Some College
Associate's Degree
Bachelor's Degree
Master's Degree or Higher
I do not wish to share
Save
Submit
Should be Empty: