Youth Registration Form
This form is required for each youth receiving any type of service through I'RAISE.
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Youth Name *
(First, Last, Middle Initial)
Date of Birth *
Address *
Street Number, Borough, Zip Code, State
Home Number *
Mobile Number *
Parent/s or Guardian/s Name *
(First, Last)
Parent/s Phone Number *
Parents Address *
Street, Borough, Zip Code, State
Parent Email
Emergency Contact Name *
Emergency Contact Number *
Emergency Contact Email *
Emergency Contact Address *
Street Number, Borough, Zip Code, State
Youth School Name *
Grade Level *
Indicate Program of Interests *
Yes Interested
Not Interested
Family Counseling 
Individual Counseling 
Group Counseling 
Big Brother Big Sister Mentoring 
Dance/ Performing Arts 
Early Scholars Tutor 
College Prep 
Entrepreneur Academy  
Please indicate Child T-Shirt Size
Clear selection
Please list your child hobbies and interests? *
What is your child career goal/s?
Child Doctor Name *
The information you provide here will be held in the strictest confidence. It will be kept on file in the kids records and maintained in case of medical emergencies. Health information is also needed in order to ensure child’s health when participating in I’RAISE groups/programs/activities.
Child Doctor Number *
The information you provide here will be held in the strictest confidence. It will be kept on file in the kids records and maintained in case of medical emergencies. Health information is also needed in order to ensure child’s health when participating in I’RAISE groups/programs/activities.
Child Doctor Address
The information you provide here will be held in the strictest confidence. It will be kept on file in the kids records and maintained in case of medical emergencies. Health information is also needed in order to ensure child’s health when participating in I’RAISE groups/programs/activities.
Does your child have any allergies? *
If yes, please describe the severity of the reaction, requested accommodations and what is done to manage them.
May we serve your child food and beverages? *
Please indicate any medical/physical and/or emotional conditions your child may have. If your child does have any conditions, please provide information to assist us in providing the best experience for your child. *
Medical, Physical, or Emotional Conditions (including Disabilities):  
If your child must take medication while participating in I’RAISE activities, please note here. Program does not administer medications to any child at any time. Please also note program does not store any medications. In the case child will need medication administered, parent or guardian must come and administer the medication to the child.   *
Medications (including Inhalers):
Is your child up-to-date on all state-required immunizations? *
AUTHORIZATION OF CONSENT  I understand that all the information on this form is voluntarily supplied and may be used and disclosed for emergency and/or office purposes only. I also agree to release and hold harmless the staff, the volunteers, and the board of directors of I’RAISE Girls & Boys International Corporation from any and all liability for disclosing this information to government agencies and their agents, and/or donors, who request information of youth enrolled in program.  I hereby agree to participate in I’RAISE Groups and maintain the confidentiality of group members. I understand that information that I disclose in groups will be held in confidentially and will not be disclosed to any individual or organization including parent and/or guardian except given verbal or written permission by the youth AND in the event a youth discloses that they want to harm themselves or another individual, parents/guardians will be contacted.   By becoming an I’RAISE Youth member, I understand that I will have the opportunity to participate in many individual and group activities, programs and events, trips, community organizing. I further understand that I’RAISE is rooted in Christian beliefs and principles and by becoming an I’RAISE Youth member; I am agreeing to respect the religious views and standards of I’RAISE Girls & Boys International Corporation, Therefore, legal action cannot be taken against I’RAISE for teaching Christian principles, Christian beliefs and/or Christian standards to youth.    By signing this application, I grant permission for participation in events without requiring additional permission forms. I hereby grant permission for I’RAISE Girls & Boys International Corporation to take my child on trips via public transportation, private bus companies, parental consent must be received when arranging other transportation methods. I hereby grant permission to the I’RAISE Girls & Boys International Corporation to take my child photo while participating in the activities to use for publicity.   I have read this entire Informed Consent Agreement.  I fully understand it and I agree to be legally bound by it. *
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