Reading is Fundamental Application Question Title * 1. Participant’s Name (First and Last) Question Title * 2. School Question Title * 3. Grade going in to Fall 2017 8th 9th 10th 11th 12th Other (please specify) Question Title * 4. Gender Female Male Other Question Title * 5. Student’s School ID Number Question Title * 6. Birthdate Question Title * 7. Age Question Title * 8. Student’s Cell Phone (if applicable) Question Title * 9. Student’s E-Mail Address Question Title * 10. Home Address (Street, City, Zip) Question Title * 11. Has participant been a PRO participant before? Yes No Question Title * 12. What are the best ways to reach the participant? Text Email Call Other (please specify): Question Title * 13. List any food allergies, special considerations, or needs we should be aware of. Question Title * 14. How did you hear about the program? Question Title * 15. What is the participant’s T-Shirt size? XS S M L XL XXL Question Title * 16. Race/Ethnicity African American/Black Asian or Asian American Hispanic or Latino Native American or Alaska Native Native Hawaiian or Pacific Islander Multiracial or Multiethnic White (not Hispanic) Other: Question Title * 17. Primary Language Spoken at Home Chinese English Hmong Russian Spanish Tagalog Vietnamese Other: Question Title * 18. Does the student receive free/reduced cost school meals? Yes No Question Title * 19. Did either of the student’s parents/guardians attend college? Yes No Question Title * 20. STUDENT AGREEMENTPlease read the following carefully: I understand that my commitment to participate in this program requires that I attend weekly meetings for the duration of the program term unless otherwise stated by my Program Site Coordinator. I understand that if I am unable to meet or commit to the requirements at any time, that I may be released from the program. I am aware of the opportunities available to me, and the responsibilities required of me as an active participant in the program. If accepted, I am prepared to fulfill the commitment that is asked of all members. I have discussed the time commitment with my parents/caregiver and all others who may be affected by my participation in this program including other clubs, programs, and my coaches. I understand that as a member of this program, I am committed to living a tobacco, drug, alcohol, and violence free lifestyle and I will abide by the program rules and boundaries discussed during my program orientation and training. Name: Date: The sections below must be completed by the student’s parent/guardian. Question Title * 21. Parent/Guardian Information Name Email Address Phone Number Mailing Address (if different from student's) Question Title * 22. TRANSPORTATION RELEASEI understand that PRO Youth and Families does not provide transportation to any students participating in their programs. I understand that my student and I are responsible for coordinating transportation to and from program activities, on or off school campus which may include field trips, meetings, and presentations for youth participating in programming. PRO Youth and Families and its employees and agents assume no liability related to such accompaniment or transportation of for any injuries or damages that occur while traveling from a PRO Youth and Families program during the time of attendance at or are participating in the activity.Do you grant permission for your child to participate in activities/events that are located away from the regular meeting site? i DO. I DO NOT . Question Title * 23. MEDIA RELEASEI understand that my child’s image may be captured on video and/or photographed during events, activities whether by PRO Youth and Families or by media organizations that may cover events or activities. I give permission for my child to participate and be videotaped and photographed. I also understand that no compensation is provided for any appearance or statements recorded by PRO Youth and Families programs or any media.Do you grant permission for your child share his/her experiences in the program via public media broadcasts, such as, but not limited to television, radio, social media and newspaper. i DO. I DO NOT . Question Title * 24. PROGRAM UPDATESI would like to be sent updates regarding PRO Youth and Families activities and opportunities during the 2017-18 school year. Yes, please send me updates. No, do not send me updates. Question Title * 25. PARENT/LEGAL GUARDIAN CONSENT & LIABILITY WAIVERI hereby give my permission for my child to take part in the Reading is Fundamental Program, a program of PRO Youth and Families. I am aware that my child will attend program meetings from June 26-August 3 on Tuesdays and Thursdays from 2:30 pm to 4:00 pm and will have to provide their own transportation. PRO Youth and Families Inc.’s mission is to inspire, educate, and mobilize young people to build a healthy future for themselves, their families, and their communities and they accomplish this mission through programs, policies, advocacy and education. I hereby allow my son/daughter, for whom I am the legal guardian, to participate in programs of PRO Youth and Families, Inc. I hereby agree to hold harmless, PRO Youth and Families, Inc., its employees and agents from and against all claims, losses, or liability, including injury associated with his/her participation in programs of PRO Youth and Families, Inc. I understand that my child will be subject to certain rules and boundaries as outlined in their program’s orientation and training and that PRO Youth and Families, Inc. is not responsible for the actions of my child or other program participants outside of program time when not under the guidance of PRO Youth and Families, Inc. staff. Parent/Guardian Name: Date: Question Title Submit your application!
