Program Application Program NameKidz Mean Business Ages 13 - 18Kidz Mean Business Youth Pop Up ShopsSmart Shoppers Program Ages 18+Youth Financial Literacy Ages 6 - 8Youth Financial Literacy Ages 9 - 12Kidz Mean Business Ages 13 - 18Thursday January 5, 2023 at LCCC Allentown CampusThursday March 9, 2023 location TBDThis is an 8-week program for 2 hours a session. The session will be once a week from 4:00 pm - 6:00 pm beginning with your selected start date. Kidz Mean Business Youth Pop Up ShopsSaturday January 14, 2022 at Downtown Allentown Market 22 N 7th Street, Allentown, PA 18101 11:00am-1:00pmTBDTBDEach Pop-Up Shop is for the time and date selected. One 8' table and two chairs will be provided. Decorate your table to represent you and your business. This is your time to shine as a young entrepreneur. All vendors must arrive one hour prior to event for check in and set up. At least one parent/guardian must be present during the event (If under the age of 18). Smart Shoppers ProgramTuesday January 17, 2023 at LCCC AllentownTuesday February 21, 2023 at LCCC AllentownTuesday March 21, 2023 at LCCC AllentownThis is a 2-hour program. The session will be from 4:00 pm - 6:00 pm on the date selected. Please bring with you: Smart device, most recent purchase receipt of any kind (within 7 days), any clothing or item you wish to turn into cash. Youth Financial LiteracyTBDTBDTBDThis is an 4-week program for 1 hour sessions. Date, time, and location TBD.Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Person to contact in case of emergency* First Last Emergency contact phone*Youth Entrepreneur InformationBusiness NameDescribe your business/productName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Age*Sex Male Female Birth Date* Date Format: MM slash DD slash YYYY Ethnic BackgroundName of the adult that will be in attendance:Parents or Guardians’ InformationName of Parent/Guardian* First Last CellHomeEmail Address Name of Parent/Guardian #2 First Last CellHomeEmail Address School informationName of SchoolGradeStudent InformationName* First Last Do you currently have a business or business idea?*YesNoWhat is the name of your business?Please describe your business or business idea.Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Age*Sex Male Female Birth Date* Date Format: MM slash DD slash YYYY Ethnic BackgroundWhat program is your child interested in?Youth Financial Literacy Ages 9 - 12What program is your child interested in?Kidz Mean Business Ages 13 - 18TransportationI will pick up my childMy child will walk homeMy child will be driving him/herselfName of the person that will pick up my child:Parents or Guardians’ InformationName of Parent/Guardian* First Last CellHomeEmail Address Name of Parent/Guardian #2 First Last CellHomeEmail Address School informationName of SchoolGradeWhat are your child’s strengths and weaknesses?1. Person to Notify in Case of EmergencyName First Last CellHomeWork2. Person to Notify in Case of EmergencyName First Last CellHomeWorkMedical InformationDoctor’s NameHospital NameAllergies (such as Peanuts etc.)In case of Emergency, Valley Wealth Alliance has permission to take your child to be treated at a professional facility* Yes No Guardian Signature*AUTHORIZATION TO RELEASE INFORMATIONI (Parent/guardian) authorize Valley Wealth Alliance, 931 Hamilton Street, Allentown Pa 18101 to constructively release, receive, and exchange information with: the school district, police department, health services, etc. in regard to my child. I would like to provide the best assistance for my child and help strengthen his/her positive involvement and success in after school activities.Name of Child First Last Date of Birth Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSchoolGrade✓ Administrative records ✓ Appropriate Agency Reports ✓ Attendance Records ✓ Educational Testing ✓ Individual Educational Plan (IEP) ✓ Lab results ✓Medical records ✓Medication records ✓ Psychological evaluation ✓ Specialist Reports ✓ Verbal-Written Information ExchangeThis authorization is in effect for one calendar year from today: Date Format: MM slash DD slash YYYY Signature of parent or legal guardian*• This information has been disclosed from records protected by state and federal confidentiality rules and regulations. These rules prohibit both parties from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by statute, regulations, or federal rules. • Both parties agree to indemnify and hold harmless the above-named agencies/individuals from any liability that may arise from the records release/receipt contemplated herein. Unless revoked, this authorization will remain in effect for a period of one year from the date of signature, or until the purpose of the authorization has been realized, whichever comes first. I may revoke this authorization by notifying the disclosing medical records/health information department in writing. • I understand that the records received will remain confidential, and I have the right to inspect any material to be disclosed • A PHOTOCOPY OF THIS RELEASE IS AS VALID AS THE ORIGINAL • REDISCLOSURE NOTICE: I understand that information used or disclosed based on this authorization may be subject to re-disclosure and no longer protected by Federal privacy standards • Enrollment will not be conditioned on obtaining the individual’s authorization or if conditioning is permitted by privacy rule a statement about the consequences of refusing to sign is authorized.Photographs, Films/Videos Release FormI give permission to Valley Wealth Alliance and other affiliate agencies to use photographs and films/videos of myself and/or my child for educational or promotional purposes. These materials may be utilized for immediate or future use. I understand that the photographs/films/videos will not be used for commercial purposes.Signature, parent/guardian must sign for children under 18*Date* Date Format: MM slash DD slash YYYY Field Trip PermissionI (Parent/Guardian) give permission for my child to go on field trips with Valley Wealth Alliance during the After School / Summer ProgramsParent/Guardian Signature*Parent/Guardian Name First Last Date Date Format: MM slash DD slash YYYY Student Name First Last Home PhoneName First Last CellHomeWorkDoctor's NamePreferred HospitalAllergies (such as Peanuts etc.)In case of emergency, Valley Wealth Alliance has permission to take your child to be treated at a professional facility Yes No Guardian Signature*