Youth Development Survey

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For parents/guardians

Name *

Address *

Waiver and Release *

I hereby release and hold harmless MECCA Development Corporation, its officers, directors, coordinators, employees, volunteers, and other attendees from any and all liability for any injury or damage resulting from, or in any way connected with, my or my child's participation in MECCA sponsored activities at the 2019 Annual Community Event.

Required

Photographic Release *

I have read and hereby grant and convey unto MECCA Development Corporation all right, title and interest in any and all photos, film, digital imaging, videos, audio recordings, verbal and written statements made by MECCA, including but not limited to, any royalties, proceeds or other benefits derived from such listed photographs or recordings. I also grant the right to use my name, likeness, voice or biographical information or any publicity including me at the event/activity.

Required

Are you expecting a child (pregnant)? *

Yes

What is the gender and age of your child(ren)

Boy

Girl

Under 5

Age 5-8

Age 9-12

Age 13-15

Age 16-18

First Child

Second Child

Third Child

Fourth Child

Fifth Child

Sixth Child

Which workshop(s) would you like your child(ren) to participate?

Conflict Resolution

Coding

Financial Literacy

Robotics

Etiquette

Reading

Drug Prevention

First Child

Second Child

Third Child

Fourth Child

Fifth Child

Sixth Child

Which activities would you like your child(ren) to participate?

Volleyball

Chess

Martial Arts

Theatre

Basketball

Dance

Cooking

Photography

Football

First Child

Second Child

Third Child

Fourth Child

Fifth Child

Sixth Child

What school does your child(ren) attend?

Clark Elementary

Marquette

St. Clare of Montefalco

Ronald Brown

Chandler Park Academy

East English Village Prep

Denby

Other

First Child

Second Child

Third Child

Fourth Child

Fifth Child

Sixth Child

When would you prefer youth development activities be held? *

Summer time (June - August)

Fall semester (September - November)

Winter semester (January - March)

Required

Does your child(ren) have reliable transportation to participate in after school (5-8pm) or weekend activities? *

Yes

Are you interested in helping us create new programs for the youth in our community? *

Yes

Maybe

What are your greatest family needs?

Food

Utility Assistance

Transportation

Childcare

Health Services

Other:

Email address (to receive program updates)

Cell Number (for text updates)

Submit

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