Project B.L.U.E. Registration and Consent Form

Youth Registration, Participation, Emergency Medical Authorization, Media Release, Communication Consent, Food Allergy Information, and Program Evaluation Consent Form

Ages: 10–18 | Cost: Free | Limited Space Available

Project B.L.U.E. is a youth leadership and community engagement initiative designed to strengthen communication skills, leadership development, conflict resolution, community engagement, and positive relationships between youth and law enforcement professionals.

Project B.L.U.E. is a partnership between C.H.O.I.C.E., Inc., LMPD PAL, JCPS Police, and community partners.

Please complete form below

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Registration is Completed for the Following (Select all that Apply)

Youth Participant

Adult Volunteer

YOUTH PARTICIPANT INFORMATION

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Youth Name (Required.)

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Date of Birth (Required.)

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Age (Required.)

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Youth Participant's Race

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Other (please specify)

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Current School (Required.)

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Grade (Required.)

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Home Address (Required.)

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Current Neighborhood (Required.)

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Parent/Guardian Name (Required.)

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Do you wish to be an adult volunteer? (Required.)

Yes

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Relationship to Youth (Required.)

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Mobile Phone Number (Required.)

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Email (Required.)

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Parent/ Guardian or Volunteer race or ethnicity? (Required.)

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Another race or ethnicity, please describe below

Self-describe below:

I give permission for my child to take part in Project B.L.U.E. activities offered by C.H.O.I.C.E., Inc. and its partners.

I understand that activities may include leadership lessons, team-building games, communication and conflict resolution workshops, mentoring activities, community service projects, fishing, gaming, archery, outdoor activities, and other supervised events.

I understand that taking part in these activities may involve some risks, such as physical activity, being outdoors, weather conditions, fishing and archery equipment, food allergies, and other program-related activities.

By signing this form, I accept these risks and agree not to hold C.H.O.I.C.E., Inc., LMPD PAL, JCPS Police, event locations, sponsors, volunteers, or community partners responsible for injuries or damages, except in cases of serious negligence or intentional wrongdoing.

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Do you give permission for your child to participate in Project B.L.U.E. activities? (Required.)

YES

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Please select all events your child plans to attend: (Required.)

Registration Closed -July 18, 2026 | Project B.L.U.E. Kick-Off Event @ Flaget Retreat Center, 1935 Lewiston Drive, 40216 (Off Dixie Hwy)

August 22, 2026 | Project B.L.U.E. Fishing Event- Location to be Announced

October 17, 2026 | Project B.L.U.E. Archery Event-South Louisville Community Center

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Project B.L.U.E. uses the BAND App as its primary communication platform for participants and families. Families are strongly encouraged to join the official Project B.L.U.E. BAND group to stay informed throughout the program year.

Will you join the BAND App? (Required.)

YES

Join Project B.L.U.E. BAND App HERE:

https://band.us/n/ada2b99cbcL1d

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If NO, please select an alternate communication method:

Text

Phone Call

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Project B.L.U.E. may photograph, videotape, record, or otherwise capture images, audio, video, and testimonials during program activities.

Please indicate your preferences below.

Photo and Video Permission - Check your choices (Required.)

Internal Reports and Grants

Newsletters, Flyers, and Website

Social Media (Facebook, Instagram, etc.)

None of the above

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Project B.L.U.E. participants are responsible for their own transportation to and from program activities. Drop-off and pick-up locations and instructions will be shared with families before each event.

Who will pick up your child? (Required.)

Parent/Guardian

Authorized Adult

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Authorized Adult Name (Required.)

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Authorized Adult Phone Number(s)

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Authorized Adult's Relationship

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I understand that my child will only be released to the parent/guardian or authorized adult listed above unless alternative arrangements are communicated and approved in advance. (Required.)

Yes

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C.H.O.I.C.E., Inc. is committed to measuring program effectiveness and improving services for youth and families.

As part of Project B.L.U.E., participants and parents/guardians may be invited to complete surveys, questionnaires, interviews, focus groups, and feedback forms before, during, and after participation.

Information collected may include:

• Demographic information
• Attendance
• Program satisfaction
• Leadership development
• Communication skills
• Conflict resolution skills
• Community engagement
• Youth perceptions of law enforcement
• Trust-building outcomes
• Social-emotional development
• Program impact measures

Participation in evaluation activities is voluntary and will not affect participation in Project B.L.U.E.

Information will be kept confidential to the extent permitted by law. Results may be reported in summary or aggregate form for grant reporting, research, program improvement, community impact reporting, educational purposes, and funding applications.

No personally identifiable information will be publicly reported without additional permission.

Please indicate your choice: (Required.)

YES, I consent to my child participating in evaluation and feedback activities.

NO, I do not consent to my child participating in evaluation and feedback activities.

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Project B.L.U.E. will provide a meal and/or snacks during each event. Every effort will be made to accommodate dietary restrictions and food allergies when possible.

Dietary Needs - Select all that apply (Required.)

None

Vegetarian

No Pork

Dairy-Free

Gluten-Free

Other

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Does your child have any food allergies? (Required.)

Yes

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If yes, list the food allergies (Required.)

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Favorite Snack (Optional)

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Does your child have any medical needs or health concerns? (Required.)

Yes

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If yes, explain the medical needs or health concerns

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Current Medications (Required.)

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If yes, explain the allergies to medicine

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In the event of an accident, injury, illness, or medical emergency and I cannot be reached, I authorize C.H.O.I.C.E., Inc., Project B.L.U.E. staff, volunteers, and designated representatives to obtain emergency medical treatment for my child as deemed necessary by licensed medical personnel.

Do you give permission for emergency medical treatment?

YES

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Emergency Contact Name (Required.)

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Emergency Contact Phone

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Emergency Contact Relationship

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Primary Physician and Phone Number (Required.)

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Health Insurance Provider & Policy Number (Optional): (Required.)

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ACKNOWLEDGMENT AND SIGNATURES

I certify that the information provided on this form is accurate and complete.

I have read and understand this registration packet and voluntarily authorize my child to participate in Project B.L.U.E. (Required.)

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Parent/Guardian's Full Name (Required.)

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Today's Date (Required.)

Select Today's Date

Date

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Scan QR code to Join BandApp

100% of survey complete.

Project B.L.U.E. Registration and Consent Form

Youth Registration, Participation, Emergency Medical Authorization, Media Release, Communication Consent, Food Allergy Information, and Program Evaluation Consent Form

Question Title

* Registration is Completed for the Following (Select all that Apply)

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* Youth Name (Required.)

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* Date of Birth (Required.)

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* Age (Required.)

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* Youth Participant's Race

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* Current School (Required.)

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* Grade (Required.)

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* Home Address (Required.)

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* Current Neighborhood (Required.)

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* Parent/Guardian Name (Required.)

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* Do you wish to be an adult volunteer? (Required.)

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* Relationship to Youth (Required.)

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* Mobile Phone Number (Required.)

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* Email (Required.)

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* Parent/ Guardian or Volunteer race or ethnicity? (Required.)

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* Do you give permission for your child to participate in Project B.L.U.E. activities? (Required.)

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* Please select all events your child plans to attend: (Required.)

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* Project B.L.U.E. uses the BAND App as its primary communication platform for participants and families. Families are strongly encouraged to join the official Project B.L.U.E. BAND group to stay informed throughout the program year.Will you join the BAND App? (Required.)

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* If NO, please select an alternate communication method:

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* Project B.L.U.E. may photograph, videotape, record, or otherwise capture images, audio, video, and testimonials during program activities.Please indicate your preferences below.Photo and Video Permission - Check your choices (Required.)

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* Project B.L.U.E. participants are responsible for their own transportation to and from program activities. Drop-off and pick-up locations and instructions will be shared with families before each event.Who will pick up your child? (Required.)

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* Authorized Adult Name (Required.)

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* Authorized Adult Phone Number(s)

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* Authorized Adult's Relationship

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* I understand that my child will only be released to the parent/guardian or authorized adult listed above unless alternative arrangements are communicated and approved in advance. (Required.)

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* Project B.L.U.E. will provide a meal and/or snacks during each event. Every effort will be made to accommodate dietary restrictions and food allergies when possible.Dietary Needs - Select all that apply (Required.)

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* Does your child have any food allergies? (Required.)

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* If yes, list the food allergies (Required.)

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* Favorite Snack (Optional)

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* Does your child have any medical needs or health concerns? (Required.)

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* If yes, explain the medical needs or health concerns

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* Current Medications (Required.)

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* If yes, explain the allergies to medicine

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* Emergency Contact Name (Required.)

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* Emergency Contact Phone

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* Emergency Contact Relationship

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* Primary Physician and Phone Number (Required.)

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* Health Insurance Provider & Policy Number (Optional): (Required.)

Registration is Completed for the Following (Select all that Apply)

Youth Name (Required.)

Date of Birth (Required.)

Age (Required.)

Youth Participant's Race

Current School (Required.)

Grade (Required.)

Home Address (Required.)

Current Neighborhood (Required.)

Parent/Guardian Name (Required.)

Do you wish to be an adult volunteer? (Required.)

Relationship to Youth (Required.)

Mobile Phone Number (Required.)

Email (Required.)

Parent/ Guardian or Volunteer race or ethnicity? (Required.)

Do you give permission for your child to participate in Project B.L.U.E. activities? (Required.)

Please select all events your child plans to attend: (Required.)

Project B.L.U.E. uses the BAND App as its primary communication platform for participants and families. Families are strongly encouraged to join the official Project B.L.U.E. BAND group to stay informed throughout the program year.

Will you join the BAND App? (Required.)

If NO, please select an alternate communication method:

Project B.L.U.E. may photograph, videotape, record, or otherwise capture images, audio, video, and testimonials during program activities.

Please indicate your preferences below.

Photo and Video Permission - Check your choices (Required.)

Project B.L.U.E. participants are responsible for their own transportation to and from program activities. Drop-off and pick-up locations and instructions will be shared with families before each event.

Who will pick up your child? (Required.)

Authorized Adult Name (Required.)

Authorized Adult Phone Number(s)

Authorized Adult's Relationship

I understand that my child will only be released to the parent/guardian or authorized adult listed above unless alternative arrangements are communicated and approved in advance. (Required.)

Project B.L.U.E. will provide a meal and/or snacks during each event. Every effort will be made to accommodate dietary restrictions and food allergies when possible.

Dietary Needs - Select all that apply (Required.)

Does your child have any food allergies? (Required.)

If yes, list the food allergies (Required.)

Favorite Snack (Optional)

Does your child have any medical needs or health concerns? (Required.)

If yes, explain the medical needs or health concerns

Current Medications (Required.)

If yes, explain the allergies to medicine

Emergency Contact Name (Required.)

Emergency Contact Phone

Emergency Contact Relationship

Primary Physician and Phone Number (Required.)

Health Insurance Provider & Policy Number (Optional): (Required.)

ACKNOWLEDGMENT AND SIGNATURES

I certify that the information provided on this form is accurate and complete.

I have read and understand this registration packet and voluntarily authorize my child to participate in Project B.L.U.E. (Required.)

Parent/Guardian's Full Name (Required.)

Today's Date (Required.)