Peace 4 Gun Violence

Chosen Path registration

Youth Program Registration & Family Welcome Package

Complete the applicable sections below. Your registration is stored privately and reviewed by authorized administrators. Individual permissions are never assumed from unanswered questions.

Download the original 20-page registration package (PDF, 3.9 MB) ↗

Enrollment and transportation require staff confirmation. Optional accessibility and family support information may be left blank. Do not upload medical documents or identification; file uploads are not requested in the original package.

* Required field. Your information is stored privately for authorized administrators.

1. Program year & youth participant information

Chosen Path Youth Program serves young people ages 5–21. Complete applicable sections. Staff will review the package and follow up. Registration does not guarantee enrollment or transportation. Fields marked * are required for online processing; other fields may be left blank when not applicable.

Program year

Youth full legal name

Preferred name / nickname

Date of birth

Age / grade

School name

Home address

City / state / ZIP

Primary language spoken at home

Youth interests / hobbies

2. Parent / guardian information

Primary parent / guardian name

Relationship to youth

Primary phone number

Email address

Home address (if different)

Secondary parent / guardian name

Relationship to youth (secondary guardian)

Secondary phone number

Secondary email address

3. Emergency contacts

List at least two people we may contact if a parent / guardian cannot be reached.

Emergency contact 1: full name

Emergency contact 1: relationship to youth

Emergency contact 1: phone number

Emergency contact 1: alternate phone

Emergency contact 2: full name

Emergency contact 2: relationship to youth

Emergency contact 2: phone number

Emergency contact 2: alternate phone

4. Authorized pickup & release

Only the people listed below may pick up the youth unless the parent / guardian provides an approved change. Photo identification may be requested. If independent release is selected, staff must approve an age-appropriate release arrangement in writing. Emergency contacts are not automatically authorized for pickup.

Authorized adult 1: full name

Authorized adult 1: relationship / phone

Authorized adult 2: full name

Authorized adult 2: relationship / phone

Authorized adult 3: full name

Authorized adult 3: relationship / phone

May the youth leave independently?

Yes No

5. Health & medical information

Do not send medication without coordinating with staff regarding storage, administration and required instructions. In an emergency, staff may call 911 and contact the parent / guardian.

Primary physician / clinic (optional)

Physician / clinic phone

Health conditions staff should know about

Medication needs during program hours

Mobility, sensory or other accommodations

Does the youth have a health action plan?

Yes No

Does the youth carry emergency medication?

Yes No

6. Allergies & dietary needs

Food may be prepared or served where common allergens are present. Families must disclose severe allergies before any meal or snack participation.

Food allergies (or write NONE)

Medication / environmental allergies

Known allergy symptoms and response instructions

Dietary restrictions or religious food needs

Foods or ingredients to avoid

Is an epinephrine auto-injector prescribed?

Yes No

Can staff contact you to clarify food needs?

Yes No

7. Transportation request

Transportation is subject to staff approval, route availability, safety requirements, and written confirmation. Completing this page is a request, not a guaranteed service. Approved riders must follow driver instructions, remain seated and use required restraints. Changes to pickup / drop-off must be approved in advance.

Transportation to program requested?

Yes No

Transportation home requested?

Yes No

Requested pickup location

Requested drop-off location

Days / times transportation is needed

Parent / guardian transportation contact

Does youth require transportation accommodations?

Yes No

8. Transportation consent

I understand that authorized program transportation, if offered, may involve designated vehicles and approved drivers. I will provide accurate contact and pickup information and communicate changes promptly. Complete this section if requesting transportation.

I authorize approved program transportation.

Yes No

I understand safety and pickup procedures.

Yes No

I request a call before finalizing a route.

Yes No

Special instructions / safety concerns

Approved alternate pickup adult / phone

Parent / Guardian Signature

Printed Name

Date

Type your name in the signature field to sign this section electronically. Review the statements and your choices before signing.

9. Hot meals & snacks

Chosen Path may provide hot meals, snacks, and beverages during selected sessions or events. Availability and menus may vary. Families should not assume that food served is allergen-free. Please also complete the allergy information section.

May the youth receive hot meals?

Yes No

May the youth receive packaged snacks?

Yes No

May the youth receive beverages?

Yes No

Preferred meal options / dietary preferences

Foods to avoid

Additional food safety instructions

Parent / Guardian Signature

Printed Name

Date

Type your name in the signature field to sign this section electronically. Review the statements and your choices before signing.

10. Program interests & goals

Tell us what matters most to your youth. Your answers help staff plan age-appropriate learning and activities.

What does the youth enjoy learning or doing?

One strength the youth brings

One goal the youth would like to reach

What support would help the youth thrive?

Leadership and confidence

Healthy friendships and boundaries

Conflict resolution and peacebuilding

Creative arts and community service

11. Participation & safety agreement

We strive to create an environment where every young person feels safe, respected and supported. Youth are expected to treat others with dignity, follow staff directions, and avoid bullying, threats, harassment and unsafe behavior. Staff may contact parents, arrange supportive interventions, or suspend participation when necessary for safety. Families may request a conversation about accommodations or concerns.

Respect other youth, volunteers and staff

Use words and actions that promote safety

Care for program materials and shared spaces

Tell a trusted adult about safety concerns

Follow arrival, departure and activity procedures

Parent / Guardian Signature

Printed Name

Date

Type your name in the signature field to sign this section electronically. Review the statements and your choices before signing.

12. Photo, video & media permission

Choose whether Chosen Path Youth Program and Peace 4 Gun Violence may use photos or video of your youth in program communications. Declining permission will not affect participation. No permission is assumed from a blank choice. A separate release may be requested for interviews, testimonials or identifiable stories. You may contact staff to withdraw future permission, although materials already distributed may not be retrievable.

Type your name in the signature field to sign this section electronically. Review the statements and your choices before signing.

13. Communication preferences

Choose how you prefer to receive updates about schedules, events, closures, and important announcements. Emergency or safety-related communications may still be made using the contact information provided.

Phone calls

Text messages

Printed notices

Preferred phone / email

Best time to contact

Preferred language

Additional communication instructions

May staff send routine program reminders?

Yes No

14. Accessibility & family support

Sharing this information is voluntary and will be handled with care. We welcome conversations about reasonable supports that can help youth participate meaningfully.

Learning, communication or accessibility needs

Helpful strategies or accommodations

Sensory or environmental considerations

Family questions or requests

Person staff should contact about support

Would you like a private follow-up call?

Yes No

15. Parent / guardian acknowledgment

By signing below, I confirm that the information I provided is accurate to the best of my knowledge. I understand that the program may contact me regarding my youth’s participation, safety, and registration details. This form is not a waiver of legal rights. Any additional event-specific or activity-specific permissions will be presented separately when needed.

I reviewed the program expectations.

Yes No

I provided emergency contact information.

Yes No

I understand permissions are selected individually.

Yes No

I understand enrollment requires confirmation.

Yes No

Parent / Guardian Signature

Printed Name

Date

Type your name in the signature field to sign this section electronically. Review the statements and your choices before signing.

16. Youth voice & commitment

For youth to complete with help from a parent / guardian if needed. I will do my best to show respect, ask for help when I need it, and encourage others.

My name is

Something I am proud of

Something I want to learn

A way I can help make my community safer

A trusted adult I can talk to

Youth signature (if age appropriate)

Date

Youth may type their name if age appropriate.

17. Final family review

Review all applicable sections before submitting. Program staff will review your registration. Enrollment requires confirmation. Your information is stored privately for authorized administrators; do not enter payment information.

All applicable pages reviewed

Allergy and emergency information provided

Permission choices clearly marked

Parent / guardian signature completed

Please review our privacy information before submitting. Avoid including information not requested by this form.