Registration/Intake Form What services are you interested in? * Youth Coach/Mentor Youth Activities & Workshops Summer Youth Program Child's Name * First Name Last Name Date of Birth * MM DD YYYY Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Male Female Ethnicity * African American/Black Caucasian Asian Hispanic/Latino Other School/ Grade * Parent's Name * First Name Last Name Phone * (###) ### #### Email * Phone (###) ### #### Parent's Name 2 First Name Last Name Phone (###) ### #### Email Emergency Contact Name * First Name Last Name Phone (###) ### #### Relationship * Primary Care Provider * Insurance Provider * Medical Info * List and explain any physical and/or mental diagnosis your child has: (special need/allergies/illnesses) Does your child have an IEP or 504 Plan? In support of what? * Is your child working with a coach or other support professional? * Photo Consent * I grant Empowered Being LLC to use photos and/or videos of my child for website, social media post and other official printed publication. Yes No Parent 's Signature * Thank you!