R.Y.T.E. (Reaching Youth Through Exercise) Intake Form

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EJ's Heart Registration Form and Emergency Information

F.A.Q.

The program is free to all students.

Transportation Provided? No
Light refreshments provided for all participants

Email *

Record my email address with my response

Student's Full Name

Gender *

Male

Female

Prefer not to say

Other:

Date of birth

YYYY

School *

Grade? *

6th

7th or 8th

Freshman

Sophomore, Junior, or Senior

Other:

Parent/Guardian Name(s)
*

Parent/Guardian Email(s)
*

Parent/Guardian Cell Phone Number(s)
*

Home phone number
*

Home address
*

2 Emergency Contacts - Adults (not parents) who will assume responsibility in case of emergency (we will call parents/guardians first). Please list 2 adults and their phone numbers.
*

Are there any medical or behavioral conditions of which we should be aware?

Yes

If yes, please state the Health Problem and the Emergency Plan.

Will your child require medication during field trips?

Yes

If yes, explain.

Please list any allergies:

Family Doctor and Phone Number:

Hospital of choice in case of emergency:

Please check the following.
*

I've read through the information letter with my child, understand the attendance obligations, and plan to attend ALL events. I understand that should I miss two events, I will be dropped from the program.

I will promptly pick up my child after each exchange.

R.Y.T.E is a EJ's Heart sanctioned activity, and all school rules apply when attending a function. I agree to abide by my school rules.

Required

I give EJ's Heart Permission to use the child's photograph or video for program-related purposes (e.g., newsletters, website, social media)
*

Yes

A copy of your responses will be emailed to .

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