Youth Wellness Program Application Form Children Wellness Program 2019 Please note, you can apply for one child only. OK Question Title * 1. 1st Parent/Guardian's details Name Email Address OK Question Title * 2. Your mobile number without the initial zero OK Question Title * 3. 2nd Parent/Guardian's details Name Email Address OK Question Title * 4. Your mobile number without the initial zero OK Question Title * 5. Preferred Method of Contact Phone Text Email Whatsapp OK Question Title * 6. Would you like to receive regular updates about the workshop? Yes No OK Question Title * 7. In case of emergency please contact Parent/Guardian 1 Parent/ Guardian 2 Other (Name/Relation/Mobile) OK Question Title * 8. Marital status of parents (Optional) Married Seperated Divorced Windowed Prefer not to answer OK Question Title * 9. Living arrangements OK Question Title * 10. Child's details Child's Name Nickname/Preferred Name Date of Birth Age School Name Year OK Question Title * 11. Child's gender Male Female OK Question Title * 12. Any medical conditions that facilitator needs to be aware of? No If Yes please explain OK Question Title * 13. Any educational challenges that facilitator needs to be aware of? No If Yes please explain OK Question Title * 14. Allergies or dietary restrictions? No If Yes please give details OK Question Title * 15. Please list siblings details (Optional) Name/s Age/s Gender School or Univesity Grade OK Question Title * 16. I give permission for my child to be photographed during the workshop Yes No OK Question Title * 17. I give permission for my child's photos to be shared on ACT Center's Instagram Account Yes No OK Question Title * 18. I give permission for my child photos to be shared on KAUST social media accounts, FB, Instagram, and KAUST Health websites. No If Yes please fill in your Instagram name OK DONE