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Number of Students Enrolling*

Please enter a number from 1 to 3.

Up to 3 students in a household, per form

Student Name*

First Name / Nombre Last Name / Apellido

Gender*

Male
Female

Date of Birth / Nacimiento*

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.

School/Escuela actualmente asistente ?*

Grade/ A qué grado asiste su hijo actualmente asistente ?*

Registering for:*

In Person Classes
Virtual (Online) Classes

Virtual Classes / Clases Virtuales

Guitar
Dance Class
Piano
Music - Voice
Art
Knitting/sewing (coming in 2022)

STUDENT 2

Student 2 Name

First Name / Nombre Last Name / Apellido

Student 2 Gender

M
F

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.

Student 2 School

Student 2 Grade

Student 2 Registering for:*

In Person Classes
Virtual (Online) Classes

Student 2 Virtual Classes

Guitar
Dance Class
Piano
Music - Voice
Art
Knitting/sewing coming in 2022

STUDENT 3

Student 3 Name

First Name / Nombre Last Name / Apellido

Student 3 Gender

M
F

Student 3 Date of Birth

Student 3 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.

Student 3 School

Student 3 Grade

Student 3 Registering for:*

In Person Classes
Virtual (Online) Classes

Student 3 Virtual Classes

Guitar
Dance Class
Piano
Music - Voice
Knitting/sewing coming in 2022
Art

Additional Information

Does your child/children qualify for free or reduced lunch? / Califica su hijo para almuerzo gratis o de bajo costo?

Yes / Sí
No

Does your family participate in any of the following programs? / Participa tu familia en alguno de los siguientes programas? CalWORKs, Calfresh, Kin-GAP, FDPIR, WIA

Yes / Sí
No

Parent or Guardian Name*

First Name / Nombre del Padre o Tutor Last Name / Apellido del Padre o Tutor

Email / Correo Electronico*

Phone*

Emergency Contact*

Adult over age of 18 please

First Last

Emergency Contact Phone*

Would you like to be part of our monthly parent support workshops ? Le gustaría ser parte de nuestros talleres mensuales de apoyo a los padres ?*

Yes - Sí
No

Annual Income in your household

Less than 40k
41k - 50k
51k - 60k
More than 60k

Do you need any assistance with the following:

Groceries
Utility bill payments
Other Financial assistance
Clothing

Address

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

Consent part 1*

RELEASE AGREEMENT AND WAIVER OF LIABILITY
In consideration of the services of Hands4HopeLA (Hands4Hope) 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 “H4HLA”), I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge H4HLA 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 here:

I consent to the Release Agreement and Waiver of Liability

Consent Covid Protocols*

COVID-19 Protocols for all participants:
I understand that participation is totally voluntary and H4HLA is not responsible or accountable in the unlikely event I / my child/children contract COVID-19 due to participation activities.

I understand and agree that any face to face activity requires a DAILY HEALTH SCREENING.
I have been provided the COVID Protocol Document (online at hands4hopela.org/covid).
Please check that site regularly for updates as COVID PROTOCOLS may CHANGE over time. I understand that any updates to that protocol will be displayed online at https://hands4hope.org/covid

I consent to follow the COVID PROTOCOLS

Consent part 3*

Online Instruction: I understand that Hands4Hope LA records all online classes. If I do not want my child’s image, voice, or representation to be included in or distributed as part of class recordings, I will turn off their video or audio prior to participating in online classes so that they are not recorded. I further understand that recorded classes may be distributed in whole or in part for marketing, promotional, or in support of Hands4Hope LA activities.

Physical Activities: I am voluntarily allowing my child to participate in Instruction offered during online classes or in person, during which they may receive information and instruction about a number of topics. I recognize that 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 prior to and regarding my child’s participation in Dance or Fitness related Instruction if they are in those classes. I warrant that I am aware of any medical condition that my child may have, which may affect their participation. I agree to fully disclose this information to H4HLA staff and its teachers.

Assumption of Risk: In consideration of my child being permitted to participate in online or in-person instruction and activities, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which might incur as a result of participation in the program.

Waiver of Claims: In consideration of my child being permitted to participate in online or in-person instruction and activities, I knowingly, voluntarily and expressly waive any claim I may have against H4HLA, staff, teachers and students, for injury or damages that they may sustain as a result of participation in the program. I, my heirs, or legal representatives forever release, waive, discharge, and covenant not to sue H4HLA, staff, teachers or students for any injury or death caused by their negligence or other acts.

Media Release: I hereby grant permission and release to H4HLAto use any photos or video images of my child/children, solely for the promotion of the program.

I consent to the above terms

Signature of Parent/Guardian*

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Email

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Registration

STUDENT 2

STUDENT 3

Additional Information

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