Afterschool Programs

While parents and caregivers are working, Hands4Hope LA is a home away from home, partnering with families to support student social, emotional and academic needs.

Registration for H4H programs, youth under 18 yrs old.

"*" indicates required fields

AFTERSCHOOL REGISTRATION

You may register up to 2 children on this form.*

# students?

Please enter a number from 1 to 2.

What is your preferred language?

Hi! How did you hear about us?

Student Name*

First Name / Nombre Last Name / Apellido

School*

Grade*

Date of Birth*

Location Requested

Ages 6-18: 11210 Otsego Street

Ages 13-18: Van Nuys 7335 Van Nuys Blvd Suite 204

Gender*

Male

Female

Other

Allergies, Medications, Physical or Mental Limitations*

Please describe any allergies (nut, foods, dust etc); and any medications the child takes.
Please also describe any activities your child may not participate in, and anything else we need to know to serve your child.

Ethnicity

How does the child identify their ethnicity?

STUDENT 2

Student 2 Name*

First Name Last Name

Location

Ages 6-18: Otsego St.

Ages 13-18: Van Nuys 7335 Van Nuys Bld Suite 204

Student 2 School*

Student 2 Grade*

Student 2 Gender*

Other

Student 2 Date of Birth*

Student 2 Allergies, Medications, Physical or Mental Limitations*

Please describe any allergies (nut, foods, dust etc); and any medications the child takes, and anything else we need to know to serve your child.

Ethnicity

How does the child identify their ethnicity?

Contact and Emergency Information

Parent or Guardian Name*

First Name Last Name

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Is there a second parent/guardian?

First Name Last Name

Phone

In Case of Emergency WHO SHOULD WE CONTACT?*

Emergency Contact's Relationship*

Emergency Contact Phone*

Additional Adult who is authorized to pick up your child / children?

(if applicable)

Full Name, relationship

Second Additional authorized adult?

(if applicable)

Full Name, relationship

Would you like to be part of our monthly parent support workshops ?*

Yes

Do you need help with transporting child/children from school to our Otsego Street location? If no, skip this section!

We have limited seats and routes available, for the Main Site (H4H on Otsego Street) only. Transportation is not guaranteed, and we will let you know ASAP if we are able to assist. You will still need to pick up your child at the end of the H4HLA program. Cost is $5 per week in advance, and payable via paypal/creditcard checkout online, or in cash in person.

Student 1 requests transportation on these days:

Monday

Tuesday

Wednesday

Thursday

Student 2 above on these days:

Monday

Tuesday

Wednesday

Thursday

LAST SECTION: demographics/survey

Thank you SO much, in advance, for completing these next questions.
Hands4HopeLA receives grants that require we provide statistics, using only combined and anonymous results of these survey questions.

Your responses help decide what kinds of programs and assistance are offered and funded.

Annual Income in your household*

Less than 40k

41k - 50k

51k - 60k

More than 60k

Do you need any assistance with the following:*

No assistance requested

Groceries

Utility payments

Clothing

Housing

Other Financial Assistance

Does your family participate in any of the following programs? CalWORKs, Calfresh, Kin-GAP, FDPIR, WIA.*

Yes

Does student qualify for free or reduced lunch?*

Yes

Are you a Veteran?*

Yes

What sex were you assigned at birth?*

Female

Male

Decline to Answer

How do you identify your gender?*

M, F, Non-Binary...other...or Decline to Answer

How do you describe your sexual orientation?*

Do you have any disabilities?*

No disabilities

Chronic health condition

Hearing difficulties

Mental disability

Physical disability

Visual difficulties

Other

Decline to Answer

How do you describe your Ethnicity?*

Is there anything else we should know?

Hands4Hope LA Afterschool Program Release Agreement & Waiver of Liability

In consideration of the services of Hands for Hope (Hands4Hope LA) and all other related entities, partners, agents, directors, advisors, officers, employees, representatives, volunteers, and all other persons acting on behalf of these entities(hereinafter collectively "Hands4Hope LA"), I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge Hands4Hope LA and its representatives on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate from any and all claims, any and all auses of action that I (we) have or may have, whether past, present or future, Whether known or unknown, whether anticipated or unanticipated, as detailed in the consent boxes below.

Signature of Parent/Guardian*

I have read the above agreement and understand fully the terms and conditions that have been explained. By signing this release agreement & waiver of liability form I am giving my child permission to attend Hands4Hope LA academic after school program.

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