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Email*

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Name*

First Last

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Phone*

Zip Code*

ZIP Code

Password*

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Do you have children under age 18 in your household?*

Yes

Expecting a Child?*

Are you expecting a child in the next 9 months?

Yes

Baby Due Date*

What is your expected due date?

MM slash DD slash YYYY

I need help with:*

Check all that apply.

Food/Nutrition

Fitness/Health Education/Healthcare Service

Stress Management/Mental Wellness

Financial/Employment/Housing/Adult Education/Business Ownership

Prenatal Care/Support

Early Childhood Education (Birth to Kindergarten)

Elementary School Youth Development

Middle School Youth Development

High School Youth Development

Other

None of the above

Other Help

FACCES programs are for expectant and existing families with children only.

Consent to Photography*

F.A.C.C.E.S has permission to use all images or likeness’ obtained during programs, events, and other activities for promotional purposes, unless otherwise expressed in writing by attendees.

I agree to the publicity and media policy.

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Consent as Custodial Parent or Guardian

By submitting this application, I confirm I am the legal custodian or guardian of the child(ren) listed below. I give permission for my child(ren) to participate in activities and program I sign up for at F.A.C.C.E.S under my membership ID.

I confirm I am the custodial parent or legal guardian.

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Consent to Liability Waiver

RELEASE AND WAIVER OF LIABILITY

The undersigned, for myself, my child(ren), or ward understands and acknowledges that play at FACCES entails both known and unknown risks including, but not limited to physical injury resulting from falling, slipping, crashing/colliding into another person, distress, damage, or death to any participant.

In consideration of being permitted to participate at events held at FACCES, I hereby voluntarily and expressly release, indemnify, and forever discharge and hold harmless FACCES and its affiliated partners.

I acknowledge and certify that I have had sufficient opportunity to read the foregoing Release and Waiver of Liability, that I understand its content, and that I execute it freely and without duress of any kind and agree to the terms therein.

I agree to the FACCES release and waiver of liability policy.

Subscribe to FACCES Family News

Sign me up for FACCES Family News.

Subscribe me to the FACCES Family Newsletter

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My Children / Family Adult Name

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My Children / Child's Name

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My Children / Gender

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My Children / Race

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My Children / Date of Birth

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My Children / Age Group

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My Children / Early Learning Program

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My Children / Other Program

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My Children / Qualify for Free or Reduced Lunch?

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My Children / School Attended

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My Children / Email

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My Children / Phone

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My Children / New Goals Activity Plan Created

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My Children / Child's Name

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My Children / Areas of Focus

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My Children / FACCES Member ID

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My Children / Assignment #2 Completed

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My Children / Assignment #3 Completed

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My Children / Assignment #4 Completed

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My Children / KRA Scores Uploaded

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My Children / Enrolled in FACCES K Ready Ohio

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My Children / CCB3 Enrolled Since

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My Children / Incentives Earned

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My Children / Eligible Incentive Reward

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My Children / Eligible Incentives

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Created By (User Id)

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Post Id

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Printed Name

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Consent to Share Information (Description)

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Consent to Share Information (Text)

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Consent to Share Information (Consent)

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PDF: FACCES Family Membership

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My Children / Assignment #1 Completed

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My Children / ASQ Completed

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FACCES programs are for expectant and existing families with children only.

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