Afterschool Program
Quiet Storm Foundation
618 South 7th Street
Las Vegas Nevada 89101

For More Information Contact Quiet Storm Foundation (702) 378-3312

(All students are required to bring study materials)

Participant Info
*First Name: Required
 *Gender:
*Last Name: Required School:
*Date of Birth:
 Required
 Grade:
*Age: Required    
 

 

 
Parent Info
    *Address: Required
*Parent Name: Required *City: A value is required.
*Phone: Required *State: Required A value is required.
*Work Phone: Required *Zip: Required
*Email: RequiredInvalid format.    

 

 

 

Emergency Contact Info
*Contact Name 1:
 Required
 *Contact Name 2:
 Required
*Phone: Required *Phone: Required
       
       
 

 

Allergies?
Hay Fever: Insects:
Milk: Poison Ivy/Oak:
Lotions: Medications:
Yes No
       
       

 

Allergies Other:

Other Info:
       
 

 

General Information
Self-Help Skills:
Functional
Poor

Social Skills:
Functional
Poor
Behavioral Skills:
Functional
Poor

Recreational Skills:
Functional
Poor

 

 

Waiver of Claim
For ourselves, and/or on behalf of our named above, our heirs, executive board, and administrators, we hereby do expressly and forever waive and release the Quiet Storm Foundation, and all their respective officers, members, volunteers, agents, and partners from any and all liability for personal injury or damages, sustained, incurred, arising from, or connected with travel to, return from any special events, and all activities related to, or in connection with said activity by ourselves or by our child. During Quiet Storm programs and events, Quiet Storm representatives may take photos of participants that may be used in professionally – designed Quiet Storm publication and promotional materials.
*I agree to the above terms: