March Madness Registration Form

Student Name: *
First Name
Middle
Last Name
Birthday:*
Age:*
Address: *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Home/Cell Phone:*
Male or Female: *
Current School*
Current Grade in March 2015: *
Mother's/Father's/Guardian's Name: *
First Name
Middle
Last Name
First Name
Middle
Last Name
Mother's/Father's/Guardian's Address: *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Mother's/Father's/Guardian's Email (Optional):
In the event of an emergency, parents or guardians will be contacted first. Please list an alternate emergency contact.
Emergency Contact: *
First Name
Middle
Last Name
Emergency Contact Address: *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Relationship:*
Daytime/Cell Phone:*
For reporting purposes and funding, please answer the following questions:
Mother's Educational Status: *
Father's Educational Status: *
Race Ethnicity: *
Current Family Status (Lives With): *
How did you hear about Hope Restoration Program?: *
Medication Adminstration: *
If yes, what medication:
Health Concerns/Activity Restrictions (My child has the following health concerns-surgies, diseases, etc., or activity restrictions):
Allergies (My child is allergic to following-foods, medications, insects, pollens, etc.):
Consent of Participation: I hereby give my permission for the applicant named above to participate in the 2015 March Madness Camp that takes place at PC Cobb Stadium, 1702 Robert B. Cullum, Dallas, TX 75210- each Sunday in March. As a condition of acceptance into the March Madness program, I hereby certify that: 1. I am the parent/legal guardian of the child name below. 2. I certify that a physician has examined my child within the past year and that she is physically fit to participate in the March Madness Camp and all its components. 3. I hereby permit Hope Restoration, Inc., True Lee Baptist Church and DISD to use, in whole or in part, photographs, videos, written extraction and voice recordings of the above named student for the purpose of illustrations, Hope Restoration , Inc., True Lee Baptist Church, and Dallas Independent School District (DISD) website, and publications. No student’s full name will be published.
Release – Waiver of Liability: I herby agree to protect Hope Restoration, Inc., True Lee Missionary Baptist Church, and DISD, all of their representatives, employees, agents, coaches, and officials, and do hereby hold all such people and entities, harmless of and from any loss, liability, claim, injury, damage, or expenses of any nature whatsoever which might be incurred, or otherwise accrue, to my child or the undersigned, by virtue of his/her participation in or being present during to include, but not limited to, travel to and from field trips whether by my own means, school provided means or otherwise.
THIS IS TO CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AUTHORIZATION CONSENT FORM. I AGREE TO ALL TERMS AND CONDITIONS CONTAINED HEREIN: