Welcome & Release Form
Contact Information
First Name
Middle Initial
Last Name
Preferred Name
Street Address
Apt Number
City
State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
Email Address
Phone Information
Home Phone Number
Cell Phone Number
Do you want to receive texts from TreeHouse?
Would you like to opt-in to receiving text messages from TreeHouse? You can expect to receive 2-4 messages per month about fun events or calendar reminders. Standard messaging and data rates will apply. You can opt-out any time.
Youth Information
Date of Birth (MM/DD/YYYY Format)
Sex
Please select...
Male
Female
Prefer not to answer
Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Mark all Races that apply to you.
Who do you live with most of the time?
Mom
Dad
Step Mom
Step Dad
Mom's Boyfriend/Partner
Dad's Girlfriend/Partner
Brother(s)
Sister(s)
Other Relatives
Foster Parent(s)
Group Home
Where do you live MOST of the time? Mark all Living Demographics that apply to you.
What grade are you in?
Please select...
6
7
8
9
10
11
12
Post High School
Are you currently enrolled in school?
Please select...
Yes
No
Which school are you currently attending?
School ID
I could not find my school on that list.
What's your school name?
Reduced/Free School Lunch
Please select...
Yes
No
How did you hear about TreeHouse?
Please select...
TreeHouse Staff
Therapist/Social Worker
Teacher/School Counselor/School Staff
Probation Officer
Pastor/Minister/Church Staff
Parent/Other Family Member
Other Teen/Friend
School Event
Who told you about TreeHouse?
Start typing your friend's name and then select their name from the list.
Referral ID
TreeHouse Site
Parent Information
Guardian
First Name
Guardian
Last Name
Guardian
Cell Phone
Guardian
Work Phone
Relationship to youth
Please select...
Mom
Dad
Step-Mom
Step-Dad
Guardian
Foster Parent
Opt Out of Release Info
My guardian needs to sign the release later
Release & Medical Info
Allergies and/or Medical Conditions/Precautions
Insurance Provider
Policy Number
Preferred Hospital
Date of Last Tetanus Vaccination
Release Language
PERMISSION/RELEASE: Your teen’s safety and welfare is TreeHouse’s primary concern. However, participation in TreeHouse programs, trips, and activities may involve risk. As parent/legal guardian of the teen(s) named above, I agree as follows: I certify that my child is in good health, free from communicable disease, and able to participate in all activities. I give permission to treat my child for routine medical care. In case of emergency, I give permission to the physician/hospital selected by TreeHouse staff to hospitalize and/or secure proper treatment for my child named above. I voluntarily agree to assume all risks related to my child’s participation in this program, trips, and activities. In case of emergency, I authorize TreeHouse to obtain necessary medical treatment for my teen and release and hold harmless releases in the exercises of this authority. I further acknowledge and understand that I will be responsible for any and all medical and related bills that may be incurred on behalf of my teen for any illness or injury my teen may sustain during TreeHouse programs or while traveling to and from site for programs. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. CONFIDENTIALITY: All one-to-one and group disclosures to TreeHouse staff, interns and volunteers are confidential unless the information shared is subject to mandated reporting guidelines. MEDIA RELEASE: TreeHouse assumes you have given permission to TreeHouse and anyone authorized by TreeHouse to use your child’s likeness, video and/or voice for future representations of the TreeHouse program. AGREEMENT TO TRANSPORT HOME: I understand TreeHouse may need to send my teen home as a result of illness, injury, discipline problems or possession of a Prohibited Item(s). I understand if my teen is dismissed from the program, trip or activity, my teen will be transported home at my expense. (TreeHouse will attempt to contact the parent or guardian to arrange such transportation.) I understand that TreeHouse may search my teen or my teen’s belongings while participating in TreeHouse programs if TreeHouse staff suspect that my teen possesses an item(s) believed to jeopardize the group’s safety or that is against TreeHouse rules. House Rules are enforced with appropriate consequences. TREEHOUSE RULES: 1. Arrive on time and stay to completion. 2. Do not arrive more than ½ hour before program or activities. 3. You will be dropped off only at your home without parent permission. You will ride home in TreeHouse vehicles or with the person you came with. 4. Drugs and alcohol are not permitted on your person or in your body. 5. Buildings, grounds, and surrounding properties are smoke-free. 6. Vans are food and pop-free. 7. All personal electronics, including cell phones, stay at home or are turned off. 8. Use respectful behavior with: 9. Communication and conversation 10. Facilities, grounds, and vehicles 11. Behaviors not permitted: -Putdowns, hurtful teasing, swearing -Inappropriate sexual language -Exclusive dating behavior -Sexual contact or harassment -Inappropriate racial language -Gang representations -Possession of a weapon on property
Electronic Signature of Parent/Guardian
Date Signed
Site ID
Site Owner
Site Email
Site Phone
Primary Contact Name
Send Parent Notification
Send