Y.O.U. After School Program Registration

Caregiver First Name Caregiver Last Name Email Phone Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code - Zip Suffix Caregiver's Primary Language Caregiver's Preferred Method of Communication Phone Text Message (Text Message Rates Apply) Email Caregiver's Preferred Time of Communication (select all that apply) What is another number we can reach you? Caregiver Status Two parent household Single parent household Alternative caregiver (i.e., grandparent, relative,etc) Special Circumstances (Please Check all that apply) Are you interested in clinical services (such as counceling or therapy) for any of the children you are registering? Number of Children Registering By selecting the option below, you consent to receive SMS text messages from Y.O.U. regarding programs and events. You will not receive any solicitation texts. Message and data rates may apply. When you receive a text from Y.O.U., you may reply STOP to unsubscribe at any time. Please note that Y.O.U. may be unable to text you until you opt in again to receive texts By selecting the option below, you consent to receive emails about Y.O.U. programs and events. You can reply to let us know you want to unsubscribe at any time. Please note that Y.O.U. may be unable to email you until you opt in again to receive emails. Media Release - As the parent/legal guardian of the child listed on this form, I give permission to Youth & Opportunity United (Y.O.U.) to record audio, images, videos or the likeness of my child during Y.O.U. programming and events throughout the academic year. I also give specific permission for Y.O.U. , at its sole discretion, to use these audio, images, videos or likeness in Y.O.U. publications, marketing and marketing and promotional material, on Y.O.U.'s website and Y.O.U's social media sites My child(ren) are permitted to participate in off site engagement and enrichment opportunities I consent to having my child(ren) participate in Y.O.U.'s After School Program I authorize my child’s school district (65 or 202) to share relevant educational information with Y.O.U., including grades, attendance, test scores, special education status, and other records needed to support my child’s participation in Y.O.U. programs. I also allow communication between school staff and Y.O.U. staff about my child’s progress. I understand my child may be asked to complete a voluntary, anonymous survey, and I may also be invited to give feedback. All information will remain confidential, and I may revoke this consent at any time.