Program Application - Valley Wealth Alliance

Program Name
Kidz Mean Business Ages 13 - 18
This 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 Shops
Each 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 Program
This 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 Literacy
This is an 4-week program for 1 hour sessions. Date, time, and location TBD.
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Person to contact in case of emergency*
First Last
Emergency contact phone*
Youth Entrepreneur Information
Business Name
Describe your business/product
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Age*
Sex
- Male
- Female
Birth Date*
Date Format: MM slash DD slash YYYY
Ethnic Background
Name of the adult that will be in attendance:
Parents or Guardians’ Information
Name of Parent/Guardian*
First Last
Cell
Home
Email Address
Name of Parent/Guardian #2
First Last
Cell
Home
Email Address
School information
Name of School
Grade
Student Information
Name*
First Last
Do you currently have a business or business idea?*
What is the name of your business?
Please describe your business or business idea.
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Age*
Sex
- Male
- Female
Birth Date*
Date Format: MM slash DD slash YYYY
Ethnic Background
What program is your child interested in?
What program is your child interested in?
Transportation
Name of the person that will pick up my child:
Parents or Guardians’ Information
Name of Parent/Guardian*
First Last
Cell
Home
Email Address
Name of Parent/Guardian #2
First Last
Cell
Home
Email Address
School information
Name of School
Grade
What are your child’s strengths and weaknesses?
1. Person to Notify in Case of Emergency
Name
First Last
Cell
Home
Work
2. Person to Notify in Case of Emergency
Name
First Last
Cell
Home
Work
Medical Information
Doctor’s Name
Hospital Name
Allergies (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 INFORMATION
I (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 State ZIP Code
Phone
School
Grade
✓ 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 Exchange
This 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 Form
I 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 Permission
I (Parent/Guardian) give permission for my child to go on field trips with Valley Wealth Alliance during the After School / Summer Programs
Parent/Guardian Signature*
Parent/Guardian Name
First Last
Date
Date Format: MM slash DD slash YYYY
Student Name
First Last
Home Phone
Name
First Last
Cell
Home
Work
Doctor's Name
Preferred Hospital
Allergies (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*

Youth Entrepreneur Information

Parents or Guardians’ Information

School information

Student Information

Parents or Guardians’ Information

School information

1. Person to Notify in Case of Emergency

2. Person to Notify in Case of Emergency

Medical Information

AUTHORIZATION TO RELEASE INFORMATION

Photographs, Films/Videos Release Form

Field Trip Permission