APRIL 26TH - WRITE 2 CONNECT YOUTH REGISTRATION PARENT/GUARDIAN INFORMATION Parent/Guardian Name * First Name Last Name Email * Phone (###) ### #### Relationship to Youth Participant * Father Mother Aunt Uncle Grandfather Grandmother Foster Parent Guardian Sibling Other - Please type your relationship to the youth below. Other Relationship to Youth Participant If you selected 'other' for relationship to youth participant, please type your response here. Are you planning to stay with your youth? * Please indicate 'Yes' if you plan to attend Write 2 Connect. If you are planning to drop your youth off and pick them up after the event, please select 'No'. Yes No EMERGENCY CONTACT INFORMATION Emergency Contact * First Name Last Name Relationship to Participant * Phone * (###) ### #### YOUTH PARTICIPANT INFORMATION Is the youth participant new or returning to Hike 2 Connect™? * New Returning Youth Participant's Name * First Name Last Name Youth Participant's Gender * Female Male Non-binary Prefer not to say Youth Participant's Age * 5 and Under 6-7 8-9 10-11 12-13 14-15 16-17 Youth Participant's Race * African American/Black Asian/Asian American Native American Hispanic/Latino White/Caucasian Other - Please type your race below. Other Race If you selected 'other' for race, please type your response here. Youth Participant's Grade * This is a family friendly activity! If your youth is not a middle school aged youth or older, they are welcome to attend the event but they must be accompanied by an adult. If this is the case, please indicate their grade in the "other" option. 6th 7th 8th 9th 10th 11th 12th Other - Please type the youth participant's grade below. Other Grade If you selected 'other' for grade please type your response here. YOUTH PARTICIPANT SURVEY It is our goal to provide a quality experiences for our youth, however, we need your input. Please complete the following short survey. What activities interest your youth? (Check all that apply) * Dance Arts & Crafts Spoken Word/Poetry Acting/Theatre Painting Drawing Entrepreneurship Fashion/Beauty Music Other - Please type your response below. Other Activities If you selected 'other' for activities, please type your response here. Has your youth hiked before? * Yes No Not Sure Does your youth enjoy outdoor activities? Yes No Not Sure What topics would you be interested in your youth learning? (Check all that apply) * Coping Skills for Anxiety Positive Body Image Self-Awareness and Self-Worth Nutrition and Wellness Social Media Safety Healthy Relationship/Friendships Other - Please type your response below. Other Topics If you selected 'other' for topics, please type your response here. WAIVER AND RELEASE H2C Waiver, Release and Assumption of Risk Agreement and Authorization for Emergency Treatment or Transportation * Please read the H2C Waiver, Release and Assumption of Risk Agreement and Authorization for Emergency Treatment or Transportation below this form and document your acknowledgement. I agree COVID-19 PRECAUTIONS COVID-19 Precautions * Please read this section and document your acknowledgement and understanding of the precautions and requirements. I agree QUESTIONS AND COMMENTS If you have any additional questions please use this space and someone will respond within 48 hours. Thank you! Waiver of Liability
