Valentine’s Day Event Please enable JavaScript in your browser to complete this form.Youth Name *FirstLastBirthdate *Age *FiveSixSevenEightNineTenElevenTwelveThirteenFourteenFifteenSixteenSeventeenEighteenGrade *KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfthParent/Guardian Name *FirstLastPhone *Address *Town/Zip *Email Address *TransportationHow will your child get home from this activity? *I will pick upOtherOther: Please specify who may pick up your child in your absenceHealth ReleaseEmergency Contact *Phone Number of Emergency Contact *Current medical condition(s) or medication we should be aware of *Physician to be called in an emergency *Physician Phone Number *Physician Address *Insurance Co.Policy #Policy Holder's NameI give my consent for the leader to contact the above named physician if my child is in need of medical care. I understand if my child's physician is not available, another physician may be contacted. I also give my consent for the leader to seek medical attention in any emergency at the nearest healthcare facility. I will be responsible for all medical charges. *Photograph/Video ReleaseI give my consent for EHYFS to photograph and/or videotape my child during this activity. I understand that my child's name and photo/video might be posted to the EHYFS website or Patch or published in printed materials such as EHYFS newsletter, newspapers.I do NOT want my child photographed or videotaped during this activity.Demographic InformationPlease note: Completing the following questions is voluntary and will not affect your child's ability to participate in the program.RaceAmerican Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/ Other Pacific IslanderMulti-RacialWhiteEthnicityHispanic/LatinoNot Hispanic/LatinoFamily2 Birth/Adoptive ParentsStep & Birth ParentSingle Parent FemaleSingle Parent MaleGrandparentRelative/GuardianDCFFoster ParentOn OwnJoint CustodyOtherFree/Reduced LunchReceives Free/Reduced LunchEligible for Free/Reduced LunchNot EligibleHomelessNot HomelessDoubled Up/Shared HousingUnshelteredHotel/MotelUnaccompanied YouthPlease check here if your child does NOT have permission to complete anonymous surveys designed to evaluate program effectiveness.Please check here if the State Board of Education does NOT have permission to obtain the State Assigned Student ID # from your child's school.Signature of Parent/Guardian *If you would like to receive updates on future Youth & Family Services activities, please provide a contact email below.CommentSubmit