Teacher's PET Intake Form "*" indicates required fields Step 1 of 5 20% Email* Class start date you are interested in enrolling in. MM slash DD slash YYYY Child First Name*Child Last Name*Address*City*State*Zip Code*Phone Number*Child's Email* Which Race or Ethnicity best describes you?* American Indian or Alaskan Native Asian/Pacific Islander Black or African American Hispanic White/Caucasian I do not know or prefer not to say Other: Other:Sex assigned at birthMaleFemalePrefer not to sayGender* Male Female Transgender Nonbinary White/Caucasian I do not know or prefer not to say Other: Other:AgeSchool Currently AttendingGrade level*Any past or present court involvement?YesNoPrefer not to say Single or Two Parent Home* Single Parent Two Parent Other: Other:(other) Guardian's NameMother's NameMother's Phone NumberMother's address if different than child'sFather's NameFather's Phone NumberFather's email Father's Address if different than child'sEmergency Contact Name*Relationship to youth participant*Emergency Contact Phone Number*Emergency Contact AddressUntitledFamily income level$15,000-$24,999$25,000-$34,999$35,000-$44,999$45,000-$54,999$55,000-$64,999$65,000-$74,999$75,000+Number of family members living in household HousingAre you a home owner or renter? Rent Home owner Parental Agreement As the parent or legal guardian of the child participating in the Teachers Pet Class, do hereby authorize my child to attend and participant in the “Teacher’s Pet” program. I hereby authorize the Toledo PET Bull Project volunteers to supervise youth only during session times and are not responsible for youth who leave the premises. I also hereby waive all claims against the “Teacher’s Pet” Program and their volunteers of any accidents, injuries, and/or wounds sustained by my child during their time at the “Teacher’s Pet” Program. I also grant my permission of the usage on any footage or pictures taken of my child for the “Teacher’s Pet” Program. I hereby acknowledge and authorize that the information contained in this Intake Form may be utilized by Toledo’s PET Bull Project and United North for referral and direct service purposes only. By typing your name bellow you acknowledge you are digitally signing this contract. Date Signed* MM slash DD slash YYYY Please Type your full legal name*PhoneThis field is for validation purposes and should be left unchanged.
