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SPRING WRAP UP REGISTRATION FORM

Grade Level

Participants Name

First Name

Last Name

Participant Age

Participant Date of Birth

YYYY

School

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name

First Name

Last Name

Relationship to Participant

Mother

Father

Legal Guardian

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Email

Parent/Guardian Work#

(###)

###

####

Parent/Guardian Mobile #

(###)

###

####

EMERGENCY CONTACT

Emergency Contact (other than parent)

First Name

Last Name

Emergency Contact relation to participant

Emergency Contact Mobile

(###)

###

####

INSURANCE

Insurance Carrier

Policy #

WAIVER & RELEASE

READ AND SIGN THE AGREEMENT/RELEASE BELOW BY TYPING YOUR FULL NAME IN THE SPACE PROVIDED..

I hereby certify that my child is in reasonable health and is capable of safe participation in the program indicated above. I assume all risks and hazards incidental to the conduct of this program. I hereby authorize the Leadership Empowerment Center to obtain medical treatment for my child in the event that the parent and emergency contact cannot be reached. 2. I hereby release the Leadership Empowerment Center, its employees, its board, and contractors from any and all causes of action and or claims for any physical injuries, personal losses, or damage done to personal property while on the premises of either the Leadership Empowerment Center, or properties associated with specific programs of the organization. 3. I agree to indemnify and save harmless the Leadership Empowerment Center from any claims or demands arising out of any such injuries or losses. 4. I authorize the publication of any photography taken for or during this program for the use of promoting or advertising further programs, unless I notify of my desire to not permit any published photos at the time of registration. SIGN THE AGREEMENT/RELEASE BELOW BY TYPING YOUR FULL NAME BELOW.

PHOTO RELEASE

By checking this box, you authorize LEC to publish or release to the media any pictures of my child during his/her time as a participant in an approved LEC program for promotional or recognition purposes ONLY.