Harris County Precinct One Youth Program Registration Form for

Create Youth Registration

Participant Information
Last Name: First:    Middle:    
Date of Birth:   Gender:
Ethnicity:   Race:
Disabled:   Homeless:
City: State:      Zip:     
School: School District: 
Household Information
Head of Household: # of Persons in Household:  
Parent/Guardian Name: Annual Household Income:
Parent/Guardian Phone:   E-mail:  
Emergency Information
  Name of local friend or relative
   (not living at same address):
Home Number:     Work Number:   
Insurance Information
 Does your child have
medical Insurance?
   Subscriber's Name:       
Insurance Company:    Doctor's Name:
Medical Insurance Group #:    Doctor's Address:
Medical Insurance Policy #:    Doctor's Phone:
Participant Medical Information
Please click on all that apply:  List any additional    
 Please click any to which  
 this child is allergic: 
Does this child take   
 medications on a   
 regular basis?   
 List any other  
 What type and how severe
 are this child's allergic 
Please list any  
medications this child  
 is currently taking:  
   Does your child have any physical conditions or limitations that might impede participation in this program? 
If Yes, please explain:    
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