Registration – Heroes Rescue Mission

Child Information
Child's Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
School*
Grade*
Adult Contact Information
Parent or Guardian's Name*
First Last
Email Address*
Enter Email Confirm Email
Home Phone*
Mother's Cell Phone
Mother's Name
Father's Cell Phone
Father's Name
Emergency Contact Name*
First Last
Emergency Contact Phone*
Primary Language*
- English
- Spanish
Medical Information
Is your child under medical care or taking any medication(s)?*
- Yes
- No
If yes, please check all of the following conditions that your child has and indicate if medication needs to be dispensed at school?*
- Bee Sting Allergy
- Asthma
- Diabetes
- Vision / Hearing
- Epi-pen
- Inhaler
- Insulin
- Glasses
- Other Allergies
- Special Needs / Disability
- Other
Other Details*
Does Heroes Rescue Mission have permission to use photos of your child in educational or promotional materials? (There is no cost)*
- Yes
- No
Legal Terms
Please Read and Sign Below*
I understand that the YHLA program is a fee base program, however, due to COVID-19, the program is offering their services free via ZOOM.
- I Agree
Parent or Guardian Signature*
I have agreed to submit this application by electronic means and typing my name is my electronic signature.
First Last
Date*
MM slash DD slash YYYY
AUTHORIZATION TO PRODUCE AND USE AUDIOVISUAL MATERIALS
Media Materials*
I hereby voluntarily and without compensation authorize Heroes Rescue Mission to produce photographs, video/audio, and PowerPoint Presentations of the above named student. This authorization is given on the condition that the materials taken or produced will be used for the purpose of community education or program promotion. I understand Heroes Rescue Mission and its staff will not use these materials for compensation. I understand that this grant of permission shall only be revoked by a written instrument delivered to the Chief Executive Officer / Chief Operating Officer of Heroes Rescue Mission. This consent shall remain in effect, unless revoked.
- I Agree
Parent or Guardian Signature*
I have agreed to submit this application by electronic means and tpying my name is my electronic signature.
First Last
Date*
MM slash DD slash YYYY
CYBER BULLYING/HARASSMENT POLICY
Cyber bullying/harassment has no place at Young Heroes Leadership Academy.*
Violation of this policy includes: • Threats (“Better watch your back”, “I’m gonna hurt you”, “We’re gonna get you”, etc.) • Harassment (always bothering someone) • Name-calling • Racial slurs • Intimidation • Sexual harassment – verbal • Spreading rumors • Extortion • Foul language • Taunting • Making insulting remarks about another student’s family members • Using the internet to harass, threaten, verbally abuse, intimidate, or spread rumors.
If your child is found to be in violation of this policy, your child will be suspended for up to one week. On the second offense, your child will be suspended for the remainder of the program.
- I Agree
Parent or Guardian Signature*
I have agreed to submit this application by electronic means and typing my name is my electronic signature.
First Last
Date*
MM slash DD slash YYYY

Child Information

Adult Contact Information

Medical Information

Legal Terms

AUTHORIZATION TO PRODUCE AND USE AUDIOVISUAL MATERIALS

CYBER BULLYING/HARASSMENT POLICY