Is the participant under 18 years old? *
Yes No
(If under 18) Parent's First Name
(If under 18) Parent's First Name
Participant First Name *
Participant Last Name *
Email *
Address *
City *
State *
Maryland
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code *
Country
none selected
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Côte D'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic People's Republic of Korea
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar(Burma)
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Ireland
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Réunion
Réunion
Sào Tomé And Príncipe
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Saudi Arabia
Scotland
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Martin
St. Pierre & Miquelon
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
US Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wales
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Telephone
Primary Langage
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact Alternate Phone
Is there anything we need to know or any accommodations that your child might require?
Legal Guardian Certification
I am allowing my minor child/ren listed below to participate in the program listed above, which will be facilitated virtually by the Housing Opportunities Commission of Montgomery County ("HOC"). I hereby certify, under the penalty of perjury, that I am the legal guardian of the children listed in this Agreement, and that I have the authority to sign this Agreement on their behalf. I agree that participating in the program is a benefit to me and my children and, in consideration of this benefit, I am signing this Agreement on behalf of myself and my children.
Media Release Acknowledgment
I consent to allow the Housing Opportunities Commission of Montgomery County (“HOC”), its nominee, or designee to reproduce, distribute, or use my name, photo, and likeness and/or that of my child/children named above, in all forms of media and in all manners, including, but not limited to, advertising, promotional materials (including video), trades, display, editorial, art, and exhibition. In granting this consent, I release HOC, its nominees, and designees, from any and all liability, claims, or obligations which may arise out of the use of such personal information.
I consent to my submitted data being collected and stored as outlined by the site Privacy Policy .