Program Application

Program Application Form Sample

Parent Information

* Indicates required fields.

Parent First Name:

Parent Email:

Parent Last Name:

Parent Phone:

Parent Address 1:

Parent Address 2:

Parent City:

Parent State:

Parent Zip/Postal Code:

How you would like to be notified?

Text Messages (SMS)

Postal Mail

Child Information

Add up to 4 Children

Child's First Name:

Child's Last Name:

Child’s Date of Birth:

Child’s Grade In School:

Emergency Contacts

Add up to 2 Emergency Contacts

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Phone:

Emergency Contact Email:

Pickup Contacts

Add up to 2 Pickup Contacts

Pick-Up Contact First Name:

Pick-Up Contact Last Name:

Pick-Up Contact Phone:

Pick-Up Contact Email:

Waiver & Consent Agreement

Please read the following agreement and indicate your consent below:

In connection with my child or ward’s voluntary involvement in activities undertaken for, and with the participation and support of [Organization Name], a non-profit charitable organization, I hereby agree, for myself, my heirs, assigns, executors, and administrators to release and discharge [Organization Name], its officers and directors, employees, agents and volunteers from all claims, demands and actions for injuries sustained to my child or ward’s person and/or property as a result of his/her involvement in such activities, whether or not resulting from negligence, and I agree to release and hold [Organization Name], its officers and directors, employees, agents and volunteers harmless from any cause or action, claim, or suit arising therewith. I hereby attest that attendance and involvement in such activities is voluntary, that he/she is participating at his/her own risk, and that I have read the foregoing terms and conditions of this release. Furthermore, I grant permission for photographs, video and quotations from my child or ward during his/her involvement with [Organization Name] to be used to further promote volunteerism.

Permission

I hereby give permission to my child or ward to participate in the Athletic Camp sponsored by [Organization Name]. I also give [Organization Name] permission to take my child or ward to the hospital in case of any emergency and to administer medication that I provide for my child.

By submitting this application, I grant [Organization Name] permission to photograph and video my child during camp activities and to use these materials for marketing, promotional, and educational purposes without compensation or further consent.

Yes, I agree with and accept the terms of the Waiver & Consent Agreement (above).

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