Participant Application Form

Participant Information *
Participant Information
Parent/Guardian Information *
Parent/Guardian Information
Contact Number *
Contact Number
Please select any conditions below that apply to the participant. *
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 Phone *
Emergency Contact #1 Phone
Emergency Contact #2
Emergency Contact #2
Emergency Contact #2 Phone
Emergency Contact #2 Phone
Authorized Pick Up #1 *
Authorized Pick Up #1
Authorized Pick Up #1 Phone *
Authorized Pick Up #1 Phone
Authorized Pick Up #2
Authorized Pick Up #2
Authorized Pick Up #2 Phone
Authorized Pick Up #2 Phone
Medical Release *
I authorize the release of information from and to my child’s primary healthcare provider and employees of My Buddy & Me solely for the use to plan and coordinate the care of my child in case of an emergency.
Photo Release *
I authorize My Buddy & Me to photograph and publish photos of my child/teen/young adult on its website and in social media solely for the purpose to expand its mission and raise awareness of the organization's work.

Upon submission of this form, you will be asked to pay a one-time $25.00 application fee. Your application will be pending until the payment is made. If you have any questions, contact us at info@mybuddyandmeatl.org.