Zen Zone - 4th grade This field is hidden when viewing the formNext Steps: Install a Payment Add-OnTo accept payments on this form you will need to install one of our payment add-ons. To learn more about your payment add-on options, visit the following page (https://www.gravityforms.com/blog/payment-add-ons). Important: Delete this tip before you publish the form.Contact DetailsChild's Name(Required) First Last Date of Birth(Required)Grade(Required)Parent's Name(Required) First Last Email(Required) Phone(Required)Address(Required) Town As a recipient of funding from the state, the following questions are required for us to ask, but you are not required to answer. All information is confidential and names are redacted before submitting to the state. Thank you for understanding.GenderChoose BelowMaleFemaleTransgenderNon BinaryChoose not to sayEthnicityChoose belowHispanic/LatinoNot Hispanic/LatinoPrefer not to answerRaceChoose BelowMultiracialWhiteBlack or African AmericanAsianNative Hawaiian or Other Pacific IslanderAmerican Indian or Alaska NativeOtherPrefer Not to SayFamily ConstellationChoose BelowTwo Birth/Adoptive ParentsSingle Parent (female)Single Parent (male)Step and Birth ParentsGrandparent(s)Relative/GuardianFoster Parent(s)On OwnJoint CustodyOtherPrefer Not to SaySuspensions in Current YearChoose BelowYesNoExpulsions in Current or Previous YearChoose BelowYes Current YearYes Previous YearYes Both YearsNoSpecial Education in Current YearChoose BelowYesNoFamily Housing StatusChoose BelowNot HomelessHomeless ShelterDoubled Up/Shared HousingUnshelteredHotel/MotelUnaccompanied MinorChoose BelowNot HomelessN/A - Homeless with FamilyHomeless ShelterUnshelteredCouch SurfingHKYFS CommunicationsHow did you hear about this event?Social MediaHK NowSchool NewsletterEmail from HKYFSHKYFS WebsiteA friendWould you like to receive once a month emails about other HKYFS events? Yes No Consent(Required) I hereby covenant and agree to release and hold harmless Youth and Family Services of Haddam-Killingworth (HKYFS), and it's agents, from and against any and all liability, loss, damage, claims, or actions (including costs and attorney fees) for bodily injury and/or property damage, to the extent permissible by law, arising out of participation in an HKYFS sponsored activity. I understand participation in a recreational activity may involve rigorous physical activity and Riss of physical injury, and I assume these risks.Photo Release - Photo Release - We like to share the great things we are doing in our community whether on the HKYFS website, social media, or HK Now. Can we include your child in photos?(Required)(Required) Yes No EmailThis field is for validation purposes and should be left unchanged. Δ
