Register

Registration for H4H programs, youth under 18 yrs old.

"*" indicates required fields

Number of Students Enrolling on this form*

Please enter a number from 1 to 2.

Hi! How did you hear about us?

What is your preferred language?

Student Name*

First Name / Nombre Last Name / Apellido

School*

Grade*

Date of Birth*

Location Requested

Ages 6-18: H4H11210 Otsego Street

Ages 13-18:Van Nuys 7334 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.

STUDENT 2

Student 2 Name*

First Name Last Name

S2Program

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.

Contact and Emergency Information

Parent or Guardian Name*

First Name Last Name

Phone*

Email*

Address

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

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

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

Clothing

Housing

Other Financial Assistance

Does student qualify for free or reduced lunch?*

Yes

I feel hopeful about my children's future

Yes

Unsure

I know how to help my children calm down when they are upset*

Yes

Unsure

I am happy when I am with my children*

Most of the time

Sometimes

Not Really

I know how to get resources that would be helpful for my children*

Yes

Unsure

I know how to help my children with challenging behaviors*

Yes

Unsure

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

Yes

Unsure

I know how to help my children with difficult thoughts*

Yes

Unsure

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

Yes

Unsure

My family is connected to the community*

Yes

Unsure

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?*

How do you describe your Ethnicity?*

Do you have any disabilities?*

No disabilities

Chronic health condition

Hearing difficulties

Mental disability

Physical disability

Visual difficulties

Other

Decline to Answer

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 Parent/Guardian*

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Registration for H4H programs, youth under 18 yrs old.

STUDENT 2

Contact and Emergency Information

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

LAST SECTION: demographics/survey

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