Student Name
*
First Name
Last Name
Age
Date Of Birth
MM
DD
YYYY
Gender
*
Pronouns
*
Race/Ethnic Background
*
Student Phone
*
Please provide a phone number that we can reach you at throughout the summer and afterwards.
(###)
###
####
Parent/Guardian Name
*
First Name
Last Name
Current Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian Phone Number
*
(###)
###
####
Parent/Guardian Email
Emergency Contact (If different than above)
First Name
Last Name
Relationship
Emergency Phone
*
(###)
###
####
Emergency Email
Do you have any food related allergies?
*
* We will be offering snacks and would like to be aware of any allergies to lower the risk of an allergic reaction.
If you answered YES, please list any food related allergies
Do you have any non-food-related allergies (e.g., bee stings, environmental, etc.)?
*
If you answered YES, please list any environmental allergies
Do you have any dietary restrictions or preferences? (e.g., vegetarian, halal, gluten-free)
*
If you answered YES, please list any food restrictions or preferences
Do you have any medical, behavioral, neurodivergence, or mental health diagnoses we should be aware of to provide appropriate care and support?
If you answered YES, please list and provide any details you would like to share.
Do you take any medications that you will need during program hours?
*
If you answered YES, please list and provide any details about these medications.
Do you have any access requirements or accommodations you would like us to know about to support your participation in the program?:
*
If you answered YES, please list and provide any details you would like to share.
Is there anything else you would like us to know?
Thank you for submitting the student intake form for the 2025 Youth FX Summer Program. We will reach out if we have any questions.
In the meantime if you have any questions at all please don’t hesitate to reach out to us by emailing info@youthfx.org
Thanks!
