Thrive Program Intake Form

Please enter your information below.

Parent/ Adult Information

First Name

Last Name

Date Of Birth

Gender

Phone Number

Current Street Address

Current City

Current State

Current Zipcode

Email Address

Preferred Method of Contact

Employment

Are you currently employed?

Place of Employment

Is this job part time or full time?

Is this job permanent?

Does this job include benefits?

Education

Please Choose the Highest Grade Completed:

Are you currently enrolled in school?

If yes, where are you currently enrolled?

If other, please list below

Date Enrolled

Anticipated Completion Date

Degree/Certification You Will Receive

Person to Notify in Case of Emergency

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Their relationship to you

Medical Background/Allergies

Please list your medical history and/or allergies below. (If none, write none)

Add an Adult

Would you like to enter another adult (18+)?

Please click "Next Page" to continue form

Your relationship to this person

Adult Information

First Name	Last Name
Date Of Birth	Phone Number
Gender	Current Street Address
Current City	Current State
Current Zipcode	Email Address
Preferred Method of Contact

Employment

Are you currently employed?

Place of Employment

Is this job part time or full time?

Is this job permanent?

Does this job include benefits?

Education

Please Choose the Highest Grade Completed:

Are you currently enrolled in school?

If yes, where are you currently enrolled?

If other, please list below

Date Enrolled

Anticipated Completion Date

Degree/Certification You Will Receive

Is this persons emergency contact someone other than you?

Person to Notify in Case of Emergency

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Emergency Contact's relationship to this person

Medical Background/Allergies

Please list your medical history and/or allergies below. (If none, write none)

Would. you like to add another adult?

To add ANOTHER ADULT, please click the blue "Add another response" button

Please click "Next Page" to continue form

Add a Student

Add an Student

Would you like to add a student (17 and younger)?

Please click "Next Page" to continue form

Student Information

Your relationship to this Student

First Name

Last Name

School

Grade Level

Date of Birth

Gender

Street Address

City

State

Mobile Number (if applicable)

Medical Background/Allergies

Please List Any Medications Currently Taken (If None write "none")

Please List Your Student's Medical History and/or Any Allergies Below. (If None write "none")

Is this person's emergency contact someone other than you?

Emergency Contact/ Pickup Permissions Information (Other than you)

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

This person's relationship to this Student(s)

Would. you like to add another student?

To add ANOTHER STUDENT, please click the blue "Add another response" button

Please click "Next Page" to continue form

Release of Liability

Release Statement

Galveston Urban Ministries Volunteer Photo Consent and Release

By signing this form, I voluntarily consent to have the photographs of those listed in this application taken and by this consent give my permission for such photograph(s) to be published. Further, if I take and submit a photograph(s) of of anyone listed in this application to GUM, I also give permission for such photograph(s) of those listed in this application to be published. I also agree that any such photograph(s) of those listed in this application referenced above in this paragraph may be published in any media including, but not limited to, newsletters, websites, videos, and press releases. I hereby also release and discharge the photographer of those listed in this application from any and all claims, including any claims for libel and/or invasion of privacy that may arise out of or in connection with the use of the photographs to which I have agreed herein.

Print Full Name and Date

Galveston Urban Ministries Emergency Medical Release

A. Provide first aid for those listed in this application to take the appropriate measures, including contacting the Emergency Medical Services (EMS) system and arranging for transportation to the nearest emergency medical facility.

B. If emergency medical care is necessary, those listed in this application are responsible for all expenses incurred as a result of medical treatment.

Print Full Name and Date

Galveston Urban Ministries Drivers Liability Waiver

I recognize and acknowledge that I am allowing all those listed in this application to travel as a passenger in personal vehicles owned by Galveston Urban Ministries Employees and volunteers as well as commercial vehicles owned by Galveston Urban Ministries. I, along with those listed in this application, assume all risks associated with this travel and agree to absolve, exonerate, and hold harmless Galveston Urban Ministries, as well as all Galveston Urban Ministries Employees and volunteers for any harm or injury resulting from this travel under the condition that all said drivers have met the requirements of the GUM Driver Eligibility Standard Policy.

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Galveston Urban Ministries Hold Harmless Waiver

I hereby waive, release, absolve, indemnify, and agree to hold harmless Galveston Urban Ministries, its directors, officers, organizers, sponsors, supervisory staff, participants, and any other affiliates: for, from, and against all liability because of any bodily injury, or property damage, known or unknown, which may occur or result from my participation in any and all activities whether the result of negligence or for any other cause of Galveston Urban Ministries. I individually have read this release and understood all of the terms. I execute it voluntarily and with full knowledge of its significance.

Print Full Name and Date