Registration and Forms | Concrete Rose Founda

Youth Application

(To be completed by the parent/guardian for youth between ages 6-18 years of age)

A commitment of $100 is due once a year at the time of enrollment

Youth's First Name

Youth's Last Name

Youth's Birthday

Name of School

Youth's Age

Grade

Parent/Guardian Information

First & Last Name

Address

Phone

Does your child have any allergies/respiratory issues?

Emergency Contact First & Last Name

Emergency Conact Phone Number

I give my informed consent and permission for my child to participate in the Concrete Rose Foundation, Inc. mentoring program and its related activities.

I release the Concrete Rose Foundation, Inc. mentoring program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Concrete Rose Foundation mentor, program staff, or other representatives, bot collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

I agree to allow the Concrete Rose Foundation to use any photographic image of my child taken while participating in the program. These images may be used in promotions or other related marketing materials.

Youth Application

(To be completed by the parent/guardian for youth between ages 6-18 years of age) *A commitment of $100 is due once a year at the time of enrollment*

Parent/Guardian Information

(To be completed by the parent/guardian for youth between ages 6-18 years of age)

A commitment of $100 is due once a year at the time of enrollment