FATE Program Registration Form
This form is created to gather general information about your interest and the programs you're looking to join.  If you have any questions, do not hesitate to contact us at info@fategroup.org or (414) 206-0076.  
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Youth Name (First) *
Youth Name (Last) *
Youth Phone Number (if applicable)
Youth Email (if applicable)
Mailing Address *
DOB (Must be 8+) *
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Parent/Guardian Details - Name. Phone. Email. *
Please List Emergency Contact(s) who are not Parent/Guardian - Name. Phone. Email. *
Total Household Members *
Health & Dietary Needs *
Required
If your child has health concerns/special needs/allergies/illnesses, please list, and advise what action steps must be taken if youth has an allergy attack, or what what precautions must be taken if youth has an illness or special needs.
What Program/Activity Are You Interested In? *
Is there anything specific youth wish to learn or accomplish by participating in our programs?
Data required by the Privacy Act of 1974
 *
Authority:  Title 10, United States Code, 5013, 5042, 5043
Principle Purpose: To provide information to FATE personnel on any health problem of an enrolled child and to have necessary information on file to contact authorised adults in case of emergency.
Routine Uses: Information is furnished to attending physicians by FATE personnel when it is necessary for youth to be taken to a medical facility by someone other than parents.  Information on medical concerns will be part of the FATE admission records.
Disclosure: Disclosure of requested information is voluntary; however, if the requested information is not provided, youth will only be accepted to FATE programs with accompanying parent or refund provided.
Consent Form: By checking below, I hereby agree and consent that if my youth(s) exhibit signs of illness or injury and FATE is unable to contact me or one of the authorized adults listed that, at the discretion of FATE personnel on duty, my youth may be transported to the nearest medical facility for medical examination/treatment deemed desirable by the personnel of the medical facility
Required
Name of Person filling out this form and Date *
Name and Date confirming consent to form and serves as signature.
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