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Office Use Only

Processed By: ____________

Amount Paid: $10 _______
Date Rec’d: ______________
Member ID#: _ _ _ _ - _ _ _ _

A complete application is required for each child. Please provide all information requested.

Date: ________________
Child's Full Legal Name: _________________________________________________ Circle One: Male / Female
Child's Preferred Name: __________________________________________ Grade in 2010-2011: 1 2 3 4 5 6
Address: ______________________________________________ City: __________________ Zip: __________
Child's SS#: ____/___/____ DOB: ___/___/___ Home Phone: _________________ Cell Phone: ______________
School: _____________________________________ Transportation: __________________________________
Race: African American / Asian / Caucasian / Hispanic / Native American / Other _________________________
• Do you have health insurance? Yes / No Name of Carrier: __________________________________
• Does the R.E.A.L. Hope Youth Center have your permission to obtain medical treatment for your child case
of emergency? Yes / No
• Does your child have any handicaps or medical conditions that would affect your child's ability to
participate in the activities of R.E.A.L. Hope Youth Center? Yes / No If yes, please explain: _________
Single Parent? Yes / No Emergency Contact:
Number living at home: _________ 1. Name: ______________________________________
Number in household under 18: __________
Phone: _________________Cell: ________________
Family Income Level (please check one level)
____ $0-$4,999 ____ $25,000-$29,999 Relationship: ________________________________
____ $ 5,000-$9,999 ____ $30,000-$34,999
2. Name: ______________________________________
____ $10,000-$14,999 ____ $35,000-$39,999
____ $15,000-$19,999 ____ $40,000-above Phone: _________________Cell: ________________
____ $20,000-$24,999
Relationship: ________________________________
Mother/Guardian Father/Guardian
Home Address
Home Phone
Cell/Other Phone
E-mail Address
I hereby make application for my child’s membership to the R.E.A.L. Hope Youth Center in Paris, Tennessee and consent to my child taking part in any and
all activities of R.E.A.L. Hope Youth Center. It is expressly understood and agreed by the undersigned that the R.E.A.L. Hope Youth Center is not liable for
the loss of property or injury unless such loss or injury results directly from negligence on the part of R.E.A.L. Hope Youth Center or from a willful act of
an employee of R.E.A.L. Hope Youth Center. I release the right to all photographic material that the R.E.A.L. Hope Youth Center might use for
promotional activities without obligation to use me or my child.

R.E.A.L. Hope Youth Center desires to serve as many children in Henry County as possible, however, enrollment is limited due to funding and space.

I fully understand and agree to all the conditions stated on this form and have counseled my child to conform to these rules of the R.E.A.L Hope Youth
Center and the authority of the employees of the R.E.A.L Hope Youth Center.

___________________________________________________________________ (Parent/Guardian Signature)

Monthly Dues: $10 (scholarships available)
* Attach cash or check payable to R.E.A.L. Hope Youth Center
MAIL APPLICATION AND FEE TO: R.E.A.L. Hope Youth Center, P.O. Box 283, Paris, TN 38242
R.E.A.L. Membership Form Rev 6-10