All District Student Registration Form

All Student Registration Form

Registration due by Friday, June 5, 2020.
This form is also used for the High School Hmong Leadership Class.
Spots are limited. The Program Coordinator will send an email to confirm registration.

Direct any questions or concerns to the Program Coordinator:
Kao Nue Xiong
kaonue.xiong@hypu.org
(916) 947-8524

1. Student Information

* Indicates required field

Legal Name *

First

Last

Hmong Name *

Date of Birth *

Age *

Gender *

2020-2021 Grade Level *

School *

School District *

Home Address *

City, State *

Zipcode *

Phone Number *

Email Address *

2. Emergency Contact Information

Parent/Guardian *

Relationship *

Contact Number *

Parent/Guardian *

Email Address *

Relationship *

Contact Number *

Email Address *

3. Medical Information

In the event of an accident or other emergency when a parent/guardian is unavailable, I hereby authorize the program to make necessary arrangements for my child to receive medical or hospital care, including transportation. I agree to pay all costs incurred. Under the above circumstances, I further authorize the physician named below to undertake such care and treatment of my child as necessary. In the event said physician is not available, I authorize such care and treatment to be performed by a licensed physician or surgeon.

Doctor's Name *

Address *

Health Coverage *

Phone Number *

City, State, Zip Code *

Hospital *

List any medications or special health care procedures: *

List any food allergies: *

4. Student Survey

Please answer the following questions as best as you can.

(a) Is your child in any of the following programs or receiving any of the following services?

(b) Check the HYPU programs your child has participated in.

(c) Student Hmong Language Fluency

(e) What are your expectations of the program?

Comment *

(f) What would you like us to know about your child?

Comment *

How did you hear about this program? *

5. Student Photo/ Video/ Product Release

I hereby give the the District and summer program, its employees, assigns and agents permission to utilize and/or publish work my child produces during summer activities and to utilize and/or publish photographs or video taken during program activities or at special events sponsored by the District and the summer program where my child may appear. These photographs, student products, and video materials may be used in publications, audiovisual presentations, promotional literature, advertising, or any other manner without compensation to the child, parents, or guardian.

By initialing below, I consent to the Photo/Video/Product Release *

6. Parent Signature

By signing, you verify that all information provided on this form are accurate.

Electronic Signature *

Date of Signature *