F.Y.R.E. Program Application

Note: Please submit one application per student.

Student Information

Legal First Name:

Last Name:

Preferred Name/Nickname:

Date of Birth:

Student's Email Address:

Please use whichever email address they check the most!

Email Type:

SchoolPersonal

Student's Phone Number:

Phone Type:

Home (Parent/Guardian)Mobile

Has this student ever been in F.Y.R.E. before?

Yes

No

What location?

What school do they currently attend?

What neighborhood do they currently live in?

Choose all that apply.

Which neighborhood?

Do they speak any other languages in addition to English (with friends or at home)?

Yes

No

What other languages?

How would they describe their race or ethnicity? (Choose all that apply)

Please specify:

If you have any questions about your child's participation in this program, please contact Jay Boss at jboss@ywboston.org

Emergency Contact Information:

First Name:

Last Name:

Emergency Phone Number:

Relationship to Student:

Please identify any physical or emotional conditions which might limit or affect participation, or make the applicant susceptible to injury:

If you have any questions about your child's participation in this program, please contact Jay Boss at jboss@ywboston.org

Media Release:

I understand that my child, alone or with other participants and/or YW Boston staff, volunteers, or representatives may be interviewed and recorded, may provide written or oral statements, and/or may be photographed by YW Boston.

I hereby grant permission to YW Boston to generate, prepare, advertise, describe, and/or publicize YW Boston and its work, goodwill, public education and/or fundraising activities, and otherwise use the photographs and interviews as they may determine, without review by me or my child and without financial or other obligation of any nature to me or my child. If you do not want your child's photo used, please submit a signed letter stating your denial of permission.

Parent/Guardian Initials:

Date:

Liability:

By signing this form, I acknowledge and agree that I am voluntarily waiving certain legal rights in good faith in order to allow participation in any YW Boston youth program or related activity. I understand that this waiver applies to myself and the minor child named previously, for whom I am the natural or legal guardian.

I recognize that participation in physical activities involves inherent risks, including the risk of injury. I agree that my child will follow all safety protocols and instructions provided by YW Boston youth program staff. I further agree to release and hold harmless YW Boston, its staff, volunteers, affiliates, and partners from any and all liability or claims arising out of participation in the program.

Parent/Guardian Initials:

Date:

If you have any questions about your child's participation in this program, please contact Jay Boss at jboss@ywboston.org

Authorization for Emergency Treatment:

I hereby give permission for the minor previously named to receive emergency medical treatment, including hospitalization, in the event I/we cannot be reached in an emergency. The completed form may be photocopied for trips outside of YW Boston/program facilities.

Parent/Guardian Initials:

Date:

Food Allergy Notice:

I understand that snacks/lunch will be provided to my child at the event. If my child has any dietary restrictions, allergies, or sensitivities I have written them below (vegetarian, gluten-free, etc.)

I understand.

Dietary Accomodations:

Check here if they do not have any dietary restrictions, known allergies, or sensitivities.

Parent/Guardian Initials:

Date:

By clicking submit and signing on the next page, I consent to my child participating in the F.Y.R.E. Program.

If you have any questions about your child's participation in this program, please contact Jay Boss at jboss@ywboston.org