Out of the Box - Youth Financial Literacy Program
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ATLANTA - Enrollment Form
To complete the application, please hit your "TAB" key to move onto the next field. Only hit the "ENTER" key upon completion of the entire form.
Student Information
Last Name
(required)
First Name
(required)
Street Address
(required)
Apt / Unit #
City
(required)
State
--Select One--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
(required)
Zip Code
(required)
Home Phone
(required)
Alternate Phone
(required)
Email Address
(valid email required)
Birth Date
(required)
Current Grade
--Select One--
9
10
11
12
(required)
Gender
--Select One--
Male
Female
(required)
School
(required)
County
(required)
Activities
(required)
College Bound
--Select One--
Yes
No
(required)
Parent / Guardian Contact Information
Mother's (Guardian) First and Last Name
(required)
Home Phone
(required)
Alternate Phone
(required)
Email Address
(valid email required)
Father's (Guardian) First and Last Name
(required)
Home Phone
(required)
Alternate Phone
(required)
Email Address
(valid email required)
Emergency Contact / Health Information
First and Last Name
(required)
Relationship
(required)
Home Phone
(required)
Alternate Phone
(required)
Please indicate if your child has any medical conditions, allergies or other conditions that we should be made aware of. If not applicable, please indicate by typing NONE
(required)
In the event of a medical emergency, I give permission for my child to be transported to a hospital for emergency medical or surgical treatment and to be treated at the hospital or in the ambulance, by a physician, qualified nurse, or emergency medical technician.
Initials
(required)
By typing your initials you are agreeing to the statement above
Student Recruitment
Refer OOTB to a qualified friend
Enter Name and Contact Information
How did you hear about us?
School Teacher / Administrator
Church
Youth Group
Radio Station
Newspaper
Online (Website)
Family Member
Friend
Parent Co-Worker
Other
(required)
Name of Refering Person / Organization
Publicity Release And Consent Form
Throughout the year, the OOTB Youth Program will conduct activities that may be publicized through local or national news media. Please indicate below if you grant permission for your child to participate in any publicity activities for events sponsored by the OOTB Youth Program. Such activities my include interview sessions with news reporters, photographs for newspapers or various publications including newsletters, calendars, brochures, videos, and photographs for the internet pages of the OOTB Youth Program. I understand that this permission is effective as long as my child attends the OOTB Youth Program or until I give further notice.
Permission Granted
Yes
No
(required)
Initials
(required)
Acceptance and Acknowledgement
Student Name
(required)
I am the Parent or Legal Guardian of above named student. I have been fully informed of the OOTB Program and give permission for my child to participate in the program. I understand that during all periods of time that my child is on the premises of OOTB or participating in any OOTB activities, he/she will be subject to the policies, rules and regulations of OOTB. I understand that as a Parent / Legal Guardian, I remain legally responsible for any personal actions taken by my child. I have read, fully understand and agree to all of the contents of the Acknowledgement / Consent Form.
Person Completing Application
--Select One--
Mother
Father
Legal Guardian
Student 18 years or older
(required)
Your Name
(required)
Accept
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