I-Park Found Sculpture – East Haddam Youth & Family Services, Inc.

Youth Name *

First

Last

Birthdate *

Age *

Grade *

Parent/Guardian Name *

First

Last

Phone *

Address *

Town/Zip *

Email Address *

Transportation

How will your child get home from this activity? *

Other: Please specify who may pick up your child in your absence

Health Release

Emergency 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 Name

I 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 Release

I 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 Information

Please note: Completing the following questions is voluntary and will not affect your child's ability to participate in the program.

Race

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Family

Free/Reduced Lunch

Receives Free/Reduced Lunch
Eligible for Free/Reduced Lunch
Not Eligible

Homeless

Please 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.