Ginew/Golden Eagle Application
Participant Information

Name:______

Address:______

City:______State:______Zip:______

Age:______Birthdate:______Boy or Girl:______# of children in family:______

Race/Tribal Background:______

School & Address Youth Attends:______

Parent/Guardian Information

Name:______Name:______

H/W Phone #:______H/W Phone #:______

Relationship to Child:______Relationship to Child:______

Annual Income (used for funding, grant purposes only):______or does your child/ren receive free or reduced school lunch? Please circle one. Yes No

Emergency Contact Information: To ensure the safety of your child in case you are not at home, Golden Eagles requires that each youth has two emergency contacts on file before attending the program. These contacts must live within our transportation zone (see attached map) and at least one of them must have a phone. Inform your contacts that they will be used as a drop-off for your child in case of emergency.

Name:______Name:______

Address:______Address:______

Phone:______Phone:______

Relationship to Child:______Relationship to Child:______

Special Needs Information

Does your child have any special needs and/or medical conditions or take medication we should know about? ______

Are there any people who are not to have contact with your child? ______

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Permission to Participate:

I give permission for my son/daughter, ______to participate in the Ginew/Golden Eagle Program at the Minneapolis American Indian Center (MAIC).

Transportation

I have received and read the transportation policy and procedures of MAIC’s Ginew/Golden Eagle Program. I give MAIC and the Ginew/Golden Eagle Program permission to provide transportation for my child to attend weekly activities and field trips offered.

Medical Emergencies

I agree and grant permission for a staff member at MAIC’s Ginew/Golden Eagle Program to act on my/our behalf in obtaining medical care for my child in the event of an injury or medical emergency. I understand that Ginew/Golden Eagles staff will not disburse any medications, including aspirin, to my child without my express verbal or written consent.

Confidentiality

I understand that all information on this application will be strictly confidential and will not be made available to anyone without my written permission.

Parent/Guardian Signature______Date______

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Photo Release: I give permission for the staff of the Ginew/Golden Eagle Program to use photos of my

child, ______, for program displays, newsletters, and promotional materials. I understand that photos will be used solely for the program and will not be altered in any way. I also give permission for my child to be included in photos or film taken by news media, such as TV or newspapers.

Parent/Guardian Signature______Date______

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OFFICE USE ONLY

Age group: 5-78-10 11+

Membership:NewReturningChange of Information

Start Date______Staff Signature______

Review Notes______

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4/9/10