Blues Registration Form

Register for this event

Event Location

Event Time / Details

Teenager's Name*

First Last

Teenager's Gender

Male
Female
Other

Race

White
Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Pacific Islander

Ethnicity

Not Hispanic or Latino
Hispanic or Latino

Teenager's Age*

Name of School Teenager Attends:*

Teenager's Grade in School*

Teenager's Email*

Teenager's Phone #*

Address

Street Address Address Line 2 City State ZIP Code

Parent's Name*

First Last

Parent's Email*

Parent's Phone*

Parental Consent*

As the parent, I give my permission for my child to participate in this program.

I give my permission for my child to participate in this program, as well as consent to have audio recording of the program if needed for instructional purposes. All program staff are bound by professional ethics of confidentiality.

Name and Organization who has referred you to COBYS Family Services:*

Comments

Consent*

I agree to and authorize the following.

By submitting this registration I authorize and agree to the following:
I authorize COBYS Family Services to provide demographic information (i.e. race, age, etc.) to funding sources and release attendance and/or participation information upon request to the funding source and the participant’s referral source.
I agree and understand COBYS Family Services provides educators. Therefore, I will not ask anyone from COBYS to be called for testimony for any future proceedings. COBYS will acknowledge attendance to classes but no other information.
I understand that COBYS staff are mandated reporters, and are required by law to report to the appropriate agency when there is reasonable cause to suspect child abuse.

Date