Youth Program Participant Form, Digital Harbor Foundation

Tech Center Youth Program Participant Form

Application ID

Contact ID

Instructions

Thank you for enrolling in a Digital Harbor Foundation Program. Complete the form below so we can prepare for the upcoming program. Details you already provided us may be pre-populated below.

If you have any questions, you can contact us directly at youthprograms@dhftc.org

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Participant Information

Participant Name

Participant Date of Birth

Gender

Race/Ethnicity

School Name

Grade

Street Address

City

State

Postal Code

Guardian Information

Name

Phone

Education, Health, & Safety Information

We collect this information to ensure we are appropriately supporting your child while they attend our programs. Sharing this information completely voluntary, and no child will be denied a program on the basis of answers provided below. Our staff may contact you if they have questions about how to best meet your child's needs.

Dietary Restrictions

Education Accommodations

Native Language

Note if other than English

Strategies to Support your Child

Note Feel free to provide details on any strategies you would like us to use to support your child.

Does your child have any of the following health conditions?

Conclusions or SeizuresDiabetesAsthma or AllergiesOther:Note Select all that apply.

Other Health Conditions

Logistical Information

Participant Student ID

Note The participant's student identification number at school.

In case of an emergency, who should we contact?

Transportation

Walk HomePick-Up by Parent/GuardianPick-up by Someone on the Authorized Pick Up ListPublic TransportationNote Check all that apply

Who is authorized to pick this child up?

Authorization and Releases

General Release

As consideration for my child’s participation in Digital Harbor Foundation's ("DHF") programs, I hereby release DHF, its successors, partners, agents, directors, volunteers, contractors, and employees individually, jointly and severally, from any and all liability for damages arising from any service or services rendered by the individuals and/or corporate entity to me or my child. Furthermore, I authorize DHF to administer brief program questionnaires for my child to evaluate the impact of DHF programs on participants and for the improvement of programs.

Photo Release

I grant permission to DHF and its partners to create and use photographic and video images, including audio recordings, of my child while participating in DHF programs. I understand that neither me nor my child will receive payment or other consideration for the use of my child’s image. I authorize DHF and its partners to edit, copy, exhibit, publish, or distribute and give up any right I may have to inspect or approve the finished product in which my child’s image may appear. I understand that recorded images of my child may be used published on the internet or in printed publications.

If you have any questions about this form, click here to contact us.