Participant Application Participant Application Registration Date * -month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -day- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   -year- 2010 2011   Today's date First Name * Middle Name Last Name * Individual Suffix - select - Jr Sr II III IV V VI VII Birth Date * -month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -day- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   -year- 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Gender * Female Male Transgender  ( unselect ) Hair Color * Eye Color * Height * Weight * Youth's Email Street Address * Street Address 2 City * Postal Code * Home Phone * Cell Phone Emergency Contact * Relationship * Emergency Phone * School * Grade * Teacher Special Needs   Academic, mental, physical, etc. Please explain clearly. Reason for coming to the program * Tutoring Mentoring Arts & Crafts Computer Sports Other How did you hear about us? * Flyer Previous Events Internet School Friend Other Health Complications   Allergy, asthma, food allergy, etc. Please explain clearly. Insurance Hospital Doctor   All information obtained from this point on will be used strictly for statistics and will NOT affect the services provided to the applicant. Eligible for free lunch at school? * Yes No  ( unselect ) Number of members in household * Ethnicity * - select - African-American Caucasian Latino Middle Eastern Native-American Annual Family Income - select - 0 - $12,000 $12,001 - $24,000 $24,001 - $36,000 $36,001 - $48,000 $48,001 + Photograph Permission * Yes No  ( unselect )   I hereby grant permission to What Now America to photograph me or my child during activities to use the photographs in What Now America audio-visual, website and printed materials without compensation or approval rights. Application Agreement * Yes No  ( unselect )   The information that I have provided is to the best of my knowledge and belief, true, correct and complete. I agree to release What Now America from all liability, claims and loss or damage arising out of the participation of my child in the program.