Youth Record

Step 1 of 5

Crossroads4Hope is a nonprofit organization funded solely through donations and grants. All of our services are offered at no charge for anyone affected by cancer. By providing your information, we are able to track participation for the purpose of improving programs and obtaining funding. All information is kept strictly confidential and secure.

Please complete this form with your child’s information. If you have more than one child, please complete it for each child individually.
Today's Date:*
MM slash DD slash YYYY
Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Address:*
Street Address City ZIP Code
County:*

PARENT / GUARDIAN INFORMATION
Parent/legal guardian’s Name:*
First Last
Parent/legal guardian’s Mobile Number:*
Parent/legal guardian’s Email Address:*
Enter Email Confirm Email
Is the parent/guardian listed above the child’s primary emergency contact?*
- Yes
- No

EMERGENCY CONTACT
Emergency Contact Name:*
To edit field, select No on "Is the parent/guardian above the child’s primary emergency contact?"
First Last
Emergency Contact Name:*
First Last
Relationship (if other than parent):
"Others" is selected, please specify:*
Emergency Contact Mobile Phone:*
To edit field, select No on "Is the parent/guardian above the child’s primary emergency contact?"
Emergency Contact Mobile Phone:*

TERMS AND CONDITIONS

By checking the boxes below, I confirm I have read this form and I understand its content and acknowledge that I take full responsibility for my child’s participation in all Crossroads4Hope programs.
Exercise Waiver: Permission for your child to participate in programs involving movement and exercise.*
I, , as ’s parent agree to take full responsibility for my child not exceeding their personal limits in the practice of a Health and Wellness program and for any injury my child might suffer during their participation in classes with Crossroads4Hope. It is my responsibility to ascertain that there is no medical reason to prevent my child’s participation in this activity and to abide by any limitations that might be set by my child’s medical providers. I do hereby agree for myself, my heirs, assigns, executors and administrators (and for any other party who may claim under or through me) to RELEASE, ACQUIT, WAIVE, DISCHARGE and FOREVER HOLD HARMLESS, Crossroads4Hope, its officers, directors, employees, agents, volunteers, affiliates, all partner agencies, subsidiaries and predecessors from any and all claims, demands, costs, expenses, rights and causes of action of any kind and nature whatsoever at law or in equity on account of all foreseen or unforeseen injuries and damages resulting from my child’s participation in any classes with Crossroads4Hope. In order to maximize the safety of my child, I agree to the following:
- I agree to discuss my child’s participation in the class with their medical provider if appropriate.
- I agree to share contact information for my child’s medical provider with the class instructor if requested.
- I agree to ensure that my child follows guidelines set out by the class instructor.
- I agree that if any changes in my child’s physical situation could affect their continued participation in the class that I will seek approval from their medical provider to continue.
Please select:
- Agree
- Disagree
Media Release: Permission for photographs or video to be taken of your child’s participation in programs.*
- As your child participates in activities at/with Crossroads4Hope, there will be times in which video footage or photographs of him/her and/or the activities he/she is participating in may be taken. Videos, photographs and statements speak volumes about the Crossroads4Hope experience and our community. Video footage and photographs taken, and statements given may be used for but are not limited to: CR4H’s website, printed materials, social media including Facebook, Instagram and Press Releases to local newspapers, the development of audio visual materials and advertisements. All of these materials illustrate the mission and philosophy of the CR4H community.
- Your permission for the use of your child’s video footage, photograph(s) and/or statements is required. Please note that your child’s face and/or any specific identifying factors will NEVER be used as it is of the utmost importance to us to protect the identity and safety of your child(ren).
Please select:
- Agree
- Disagree
Contact Release: Permission for CR4H Program Staff to release information for the purpose of supporting your child.*
- I authorize Crossroads4Hope to release information concerning my child/children’s participation in their programs.
- I am aware that, under N.J.S. 45:14B-28, I may refuse to permit the disclosure of confidential communications between me and a licensed practitioner under many circumstances. I knowingly waive, for the above purposes only, whatever right of confidentiality I may have with my knowledge of CR4H staff doing so at any circumstance. I also am aware that I may revoke this authorization at any time and that, while my revocation will not affect disclosures of information that occurred prior to the revocation, it will be effective as to subsequent requests for disclosure.
Please select:
- Agree
- Disagree
Consent*
- Consent for HIPAA Waiver and program Terms and Conditions.
Permission for Crossroads4Hope program staff to communicate directly with your child.*
- Agree
- Disagree
Child/Youth Mobile Number:
Child/Youth Email:
Enter Email Confirm Email

Step 1 of 5

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACT

TERMS AND CONDITIONS