Scholar Enrollment Form Pure Heart Foundation 2025-2026
Please complete this form to enroll your scholar (child) in the Pure Heart scholar program for 2025. Completion of this form is MANDATORY for participation in all programming, activities, field trips, and giveaways. EACH individual scholar must have a separate form completed. If you would like assistance with this form, please contact our Pure Heart Engagement Coordinator at (313) 952-3600. Once your application is completed and submitted you will be contacted to begin your family onboarding process.
Please select the Pure Heart site your Scholar(s) will participate in. *
First Name, Middle Initial, Last Name
Scholar's Gender *
- Boy
- Girl
- Non-Binary
- Prefer not to say
- Not listed
Race/Ethnicity *
Please choose all that apply.
- Black or African American
- Asian or Asian American
- Native Hawaiian or Pacific Islander
- Hispanic or Latinx
- Middle Eastern or Northern African
- Indigenous Person
- White or Caucasian
- Prefer not to say
- Not listed
Scholar's Grade Level *
- Not Currently Enrolled
- Headstart/Day Care
- Preschool
- Kindergarten
- 1st
- 2nd
- 3rd
- 4th
- 5th
- 6th
- 7th
- 8th
- 9th
- 10th
- 11th
- 12th
- High school graduate
- College/University
(2023-2024 school year)
Please upload your scholar most recent Report Card *
Attach file
Drop files here
Scholar Uniform T-Shirt/Sweatshirt Size *
Tshirt/Sweatshirt Sizing Guide (these are not exact measurements, please choose the one closest to the scholar's size):
- 3T- 4T
- Youth- XS/ 5-6
- Youth- S/ 6-7
- Youth- M/ 8-10
- Youth- L/ 12-14
- Youth- XL/ 16-18
- Adult- S
- Adult- M
- Adult- L
- Adult- XL
- Adult-2XL
- Adult- 3XL
- Adult- 4XL
Scholar Uniform Sweatpants Size *
Sweatpants Sizing Guide (these are not exact measurements, please choose the one closest to the scholar's size):
- 3T- 4T
- Youth- XS/ 5-6
- Youth- S/ 6-7
- Youth- M/ 8-10
- Youth- L/ 12-14
- Youth- XL/ 16-18
- Adult- S
- Adult- M
- Adult- L
- Adult- XL
- Adult- 2XL
- Adult- 3XL
- Adult- 4XL
Does your scholar currently have medical insurance? *
- Yes
- No
Does your scholar have any medical conditions or complex abilities/disabilities/impairments? *
Please select all that apply. Select "NONE" if none apply.
- Attention Deficit (ADHD or ADD)
- Autism Spectrum Disorder
- Learning disability
- Depression
- Anxiety
- Oppositional Defiance Disorder (ODD)
- Obsessive Compulsive Disorder (OCD)
- Post-Traumatic Stress Disorder (PTSD or C-PTSD)
- Schizophrenia or experiences hallucinations
- Other mental illness
- Asthma
- Crohn's Disease
- Irritable Bowel Syndrome
- Severe Food Allergies
- Diabetes
- Hearing Impairment
- Visual Impairment
- Heart condition
- Hyperkeratosis of hands and feet
- Seizures/Epilepsy
- Severe Allergies
- NONE
- NOT LISTED
Please list all known allergies for your scholar. *
Please select all that apply. Select "NONE" if not applicable.
- NONE
- Amoxicillin
- Cats
- Citrus
- Dandelion
- Dust
- Fish
- Mango
- Mosquito Bites
- Peanuts
- Penicillin
- Pineapples
- Seafood
- Seasonal Allergies
- Seasonal Allergies
- Strawberries
- Tree Nuts
- Not Listed
First Name, Last Name
Main Caregiver Relationship to Scholar *
Please enter your cell phone number- this allows us to communicate with you in the following ways: Call and text.
Please type "NO EMAIL" if you do not have an email address.
Our main communication tool will be through email. You will be notified about upcoming events, resources and scholar afterschool schedules through email. If you do not have an email, we can assist you with setting one up.
What is the best way to contact you? *
- Text Message
- Phone Call
- Email
- Mail
Street #, Name, and Apartment #(Ex. 100 West Street Apt. 1)
City of Residence *
County *
As the scholar's caregiver, are you currently employed? *
- Employed- Full Time
- Employed- Part Time
- Employed- Family/Medical Leave
- Laid off due to COVID pandemic
- Unemployed
- Unemployed- Job searching
- Unemployed- Unable to work
- Self employed
Household Annual Income *
Please select the amount that is most accurate to your household yearly income
Do you and your scholar have reliable transportation? *
- Yes
- No
- Sometimes
First Name, Last Name
Please list someone other than the scholar's main caregiver (you). If there is an emergency and we cannot get ahold of you, who should we call?
Emergency Contact Relationship to scholar *
Does the scholar you are currently enrolling have an incarcerated parent/guardian? *
Please provide information regarding the scholar's incarcerated parent/guardian.
If you choose "other" please explain in the following questions.
- Currently Incarcerated
- Recently Released
- Parole/Re-entry
- Currently awaiting court or trail
- Has not been sentenced yet
- Other
First Name, Last Name
Please list their name no matter their status you listed above.
Incarcerated Parent's Gender *
Please list their name no matter their status you listed above.
- Man
- Woman
- Non-Binary
- Prefer not to say
- Not listed
If they are no longer incarcerated, please list their current status.
-If unknown, please list an approximate date of release. If they are no longer incarcerated, please list their current status.
On scale from 1-10, rate your scholar's relationship with their incarcerated parent/guardian *
1= No contact/Not good
10= Amazing
If they are deceased, rate their previous relationship.
Do you give your scholar permission to communicate with their incarcerated parent through Pure Heart Foundation? *
- Yes
- No
- Maybe
- Not Possible (deceased, unknown location, etc.)
What is your biggest concern with your scholar having a parent/guardian that is currently incarcerated? *
- {name}
As a Pure Heart scholar, scholars will participate in our Holistic Model. Please select the top three programs you would want your scholar to participate in. Please note that they will have access to all programming. *
- Mental Health Wellness
- Academic Enrichment
- Mentorship
- Recreational and Arts
- Family Reunification
- Cycle Breaker Initiative
What are your expectations by your scholar participating in the Pure Heart program? *
- {name}
Are you willing to participate as a volunteer for Pure Heart Foundation field trips, and/or events? *
- Yes
- No
- Maybe
How did you hear about pure heart foundation? *
- CEO Works
- Detention Facility
- Friend/Family Member
- Google search
- Other community organization
- Social Media
- Someone currently enrolled in Pure Heart
- Other
By typing your name below, the caregiver and scholar(s) have agreed to follow the Pure Heart Foundation Code of Conduct when participating in any Pure Heart related activities.
1. You will be interacting with staff, volunteers, and guests some of whom are children. Given that, you agree to carry out your participation in an appropriate way that aligns with the program mission and values.
2. It is possible while participating in group activities other scholars may share feelings and ideas that are personal to that individual. You will not share personal and confidential information with outside parties.
3. Program activities may require additional releases and other consent forms.
4. You are free to withdraw from the program at any time with a written statement and exit survey.
By typing the scholar's full name below, they agree to:
1. Follow the pure heart scholar motto:
-Participate in the program
-Understand the guidelines
-Respect myself and others
-Empathize with others
-Honest communication
-Engage with enthusiasm
-Act responsibly
-Receive support with gratitude
-Trust in the good!
2. Not share personal information or secrets about other scholars.
3. Follow guidance of our Pure Heart leaders (chaperones, staff, etc.).
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