Parent/Guardian name *

First Name

Last Name

Phone

(###)

###

####

Please confirm your understanding that this program is intended specifically for female participants. *

I understand this program is for female youth only.

Youth's name *

First Name

Last Name

Youth's date of birth *

MM

DD

YYYY

Preferred start date *

MM

DD

YYYY

Agreement for Youth Participation *

I, the parent/guardian of the participant named above, give my permission for my child to take part in the Bloom 1 to 1 Connect program as indicated above. I understand that participation is voluntary and that the program is designed to provide guidance, support, and skill-building in a safe and supportive environment.

I consent to my child's participation in the Bloom 1 to 1 Connect program.

Consent for the Collection and Sharing of Information *

I consent to the collection and sharing of relevant information about my child with the appropriate staff for the purpose of providing guidance, support, and supervision. I understand that this information will remain confidential and used only to enhance my child’s experience.

I consent to relevant information being collected and shared with appropriate staff.

Emergency Contact Information *

I understand that in the event of an emergency involving my child, program staff will contact me or the designated emergency contact below. I agree to provide accurate and up-to-date emergency contact information to ensure my child’s safety.

I consent to program staff contacting me or the designated emergency contact in case of emergency.

Emergency Contact Name *

First Name

Last Name

Emergency contact phone *

(###)

###

####

Date

MM

DD

YYYY