Transitional Age Youth Program

TAY

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Register for TAY - program for 18 year old and up. *if you're a parent registering a child under 18, please go to the H4H program page.

Hi! How did you hear about us?

What is your preferred language?

Name*

First Name / Nombre Last Name / Apellido

Phone*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Just checking - you're over 18 and enrolling in the Transitional TAY program?*

Yes

No - I'll go back to the last question.

Hidden

Location:

Van Nuys

Date of Birth*

Allergies, Medications, Physical or Mental Limitations*

Please describe any allergies (nut, foods, dust etc); and any medications, or activities you are not able to participate in, and anything else we need to know to serve you.

In Case of Emergency WHO SHOULD WE CONTACT?*

Emergency Contact's Relationship*

Emergency Contact Phone*

We provide free programs through grants that require the following anonymized information.

Thank you SO much, in advance, for completing these next questions. We provide statistics, 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

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

Yes

Do you need any assistance with the following:*

No assistance requested

Groceries

Utility Payments

Other Financial Assistance

Clothing

I feel hopeful about my future*

Yes

Unsure

I know how to calm down when I am upset*

Yes

Unsure

I am happy*

Most of the time

Sometimes

Not really

I know how to get resources*

Yes

Unsure

I know how to manage my behaviors*

Yes

Unsure

In our family we take time to listen to each other*

Yes

Unsure

I know how to cope with difficult thoughts*

Yes

Unsure

I take good care of myself/my children despite my personal problems*

Yes

Unsure

I feel connected to the community

Yes

Unsure

What sex were you assigned at birth?*

Female

Male

Decline to Answer

How do you identify your gender?*

female, male, non-binary, other (describe), Decline to State.

How do you describe your sexual orientation?*

Do you have any disabilities?*

No disabilities

Chronic health condition

Hearing difficulties

Mental disability

Physical disability

Visual disability

Other

Decline to Answer

How do you describe your Ethnicity?*

Is there anything else we should know?

Release Agreement and Liability Waiver*

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 causes 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.

Academic Evaluation - applies to children under 18 yrs of age
I hereby give permission for the school to release any and all confidential school records to (Hands4Hope LA) for purposes of assessment and evaluation for the betterment of my child’s academic and social success and the effectiveness of Hands4Hope LA after school program.

I also hereby give permission for my child to participate in activities or surveys designed to evaluate the effectiveness of Hands4Hope LA.

Physical Activities
I am voluntarily participating / allowing my child to participate in instruction covering a number of topics. I recognize this may include fitness or dance classes may require physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician for my child (or myself if a TAY student over 18) prior to and regarding participation in dance or fitness related instruction. I warrant that I am aware of any medical condition that my child / myself if over 18 TAY student, may have, which may affect participation. I agree to fully disclose this information to Hands4Hope LA staff.

Assumption of Risk
I understand that there is an assumed risk of injury in all (Hands4Hope LA) activities. I have read and understood this agreement, and I hereby waive all claims against Hands4Hope LA and their contractual partners for injury or damage to any person or property on and off campus premises by or from any cause whatsoever including the after school program’s negligence.
I agree to hold Hands4Hope LA and their contractual partners free from any liability or responsibility for damages arising from any injuries to myself, my child, my children, or property owned by any of us.

I consent to the Release Agreement and Waiver of Liability

Signature of TAY Student (over 18 yrs old)*

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TAY

We provide free programs through grants that require the following anonymized information.

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TAY

We provide free programs through grants that require the following anonymized information.

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