📍 We've moved! Come visit HeartLove Place inside the YWCA at 1915 N Dr. Martin Luther King Jr Drive Suite #250 🙌📍 We've moved! Come visit HeartLove Place inside the YWCA at 1915 N Dr. Martin Luther King Jr Drive Suite #250 🙌📍 We've moved! Come visit HeartLove Place inside the YWCA at 1915 N Dr. Martin Luther King Jr Drive Suite #250 🙌📍 We've moved! Come visit HeartLove Place inside the YWCA at 1915 N Dr. Martin Luther King Jr Drive Suite #250 🙌📍 We've moved! Come visit HeartLove Place inside the YWCA at 1915 N Dr. Martin Luther King Jr Drive Suite #250 🙌

Youth Program

2025 Registration Form

Program

Date

1Child Information

Name

Age

Date of Birth

Gender

Race

School

Grade

2Address & Contact

Home Address

City

Zip Code

Home Phone Number

Youth's Cell Phone

3Guardians & Emergency Contact

Guardian's Name (1)

Guardian's Cell (1)

Guardian's Name (2)

Guardian's Cell (2)

Emergency Contact (Non-Parent)

Cell Number

4Health Information

Please list any health issues that your child may have that we should be aware of:

5Agreements & Releases

Hold Harmless Agreement

I understand that participation in the activity involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself or my child to participate in the activity. I understand that participation in the activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release HeartLove Place Ministries, or other organizations associated with the activity from any and all claims or liability arising out of this participation. In case of emergency involving my teen, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

Parent Agreement

I,give permission for my child,to participate in HeartLove Place Youth Programs.

I understand that my child will be expected to follow all rules associated with the programs and should he/she not; he/she may be excluded from the program.

Parent's Signature (Type Full Name)

Date

Youth Agreement

I,agree to follow the rules of HeartLove Place’s youth programs and to follow the direction of HLP staff leaders.

I understand that if I do not follow the rules I may be excluded from the program.

Youth's Signature (Type Full Name)

Date

Photo/Audio/Video Release Form

I,hereby grant HeartLove Place, its representatives and employees the right to take photographs, video and/or audio of me, and my said property, in connection with the above- identified subject (HLP).

I authorize HeartLove Place, its assigns and transferees to copyright, use and publish the same in print and /or electronically. I agree that HeartLove Place may use such photographs/video/audio of me with or without my name and for any lawful purpose, including for such purposes as publicity, illustration, advertising and web content.

I have read and agree to the above

Parent/Guardian Signature

Date

By clicking Submit, you agree to the terms and digital signatures above.