Parent / Guardian Information

Parent / Guardian Name *

Phone Number *

Emergency Contact. For Example: +254-123456789

Email *

Alternative Phone Number 1

Alternative Phone Number 2

What's your relationship with the child? *
[radio* relationship use_label_element
"Parent"
"Guardian"
"Relative"
"Foster parent"
"Teacher"
"Childcare provider"
"Other"]

Address *

Other Guardians Info

Child Information

Child Name *

Date of Birth *

Gender *
[radio* gender use_label_element
"Boy"
"Girl"]

Current Education Level *
--- Select Choice ---Pre-PrimaryLower Primary (Grade 1-3)Upper Primary (Grade 4-6)Junior SecondarySenior SecondaryNot in School

Schools Attended *

Please describe any illness, allergies, or medical conditions

Consent *

I hereby permit my child to participate in the after-school program at Nesting for Hope International.I acknowledge that in the event of an emergency, every reasonable attempt will be made to contact the person(s) whose details I have provided. If they cannot be reached, I authorize the program staff to take appropriate action to safeguard the child.I give permission for my child to be photographed and/or recorded on video during program activities for documentation, educational, promotional, or reporting purposes by the organization.