NAMI Hancock County Youth Registration Form
Please fill out this form fully to begin registration for your child in the youth programs at NAMI Hancock County. This form in addition to a brief initial parent interview completes registration. No mental health diagnoses required.

- If you want your child to attend KidShop again for the 2023-24 school year, you must fill this form out again and complete an have an additional phone conversation with the Director of Youth Engagement.
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In which program(s) are you registering your child? *
**Those over 18 are to be considered "mentors" who provide support to their younger peers.
Required
Child's full name: *
Child's birthdate: *
MM
/
DD
/
YYYY
Child's gender/identity: *
Child's school: *
Child's ethnicity (not required):
Child's grade: *
How will your child be transported to NAMI Hancock County? *
How will your child be transported from NAMI Hancock County? *
Child's home address: *
Emergency Contact(s) full name & relationship to child: *
Ex: 
Jane Doe - Mom
John Doe - Dad
Emergency contact phone number(s): *
Ex:
Mom: (123)456-7890 
Is it okay to text the above number(s) for non-emergencies? *
Additional Contacts/Pickup Persons:
Please list any additional contacts that can be contacted and have your permission to pick up up your child in an event that you cannot be reached. Include their names, their relationships to the child, and their phone numbers. Any person not listed as a primary contact or additional contact will not be permitted to pick up your child without prior confirmation.

Ex:
Jeffery Doe, uncle, (098)765-4321
Check the boxes below to agree. *
Required
If applicable, please describe any physical health conditions (i.e. allergies, asthma, diabetes, etc). Please list any medications you would like NAMI Hancock County to administer, and instructions. 
Please choose one of the options below. *
Please describe what you hope your child gains from youth programming at NAMI Hancock County:
Ex:
Coping skills, making friends, self-acceptance
Is your child more inclined to be introverted or extroverted?
Introverted
Extroverted
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If applicable, please describe your child's experience with mental health conditions (self, family and/or friends):
If applicable, please list any mental health diagnoses your child has received: 
Does your child have any particular interests or hobbies?
Please provide any additional information that you believe would help us interact with your child.
How did you hear about NAMI Hancock County? *
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