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Sand Mountain Youth Center M.O.S.H. Application
I am registering for:
Spring Break Activities____
M.O.S.H. 2000 Summer Program_____
GED Skills class_____
After-School
Program_____
Please check the following:
I would like to help with a certain subject____ What
Subject?______________________
My parents work in the afternoons, I just want to
hang out there._____________________
Youth's Name_____________________________________
Birthdate ________________
Parent's / Guardian's
Names___________________________________________________
Address__________________________________________________________
Phone Number___________________________ Emergency
Phone__________________
******************For Grant Purposes
Only....CONFIDENTIAL*****************
Please check all that apply to your family:
_____Single Parent Family
_____Blended Family (step-parents live in the home)
_____Failing a Subject
_____Qualify for Free/Reduced Meals at School
_____Medical or Learning Disability (if so, what?)
___________________________________
_____Been in Trouble with the Law or at School
***************************************************************************
(not applicable to GED Students 18 years or older)
Parents. Please read and sign:
Is there anything we need to know about your child's medical or physical
limitations?___________
My child has my permission to
participate in the programs at the Sand Mountain Youth Center.
This may include field trips or other activities. I hereby waive
any and all claims against the Sand Mountain Youth Center and the
leaders thereof for any injuries to said child as a result of trip or
activity.
Parent's
Signature______________________________________________ Date_______
Return to : Sand Mountain Youth Center PO Box 2497 Rainsville, AL
35986
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