GoByk Registration and Emergency Contact
First Child's Name
First Name
Last Name
Age
Sex
Male
Female
Prefer not to answer
2023-24 Grade Level
Second Child's Name
First Name
Last Name
Age
Sex
Male
Female
2023-24 Grade Level
Third Child's Name
First Name
Last Name
Age
Sex
Male
Female
2023-24 Grade Level
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Relationship
Cell Phone
-
Area Code
Phone Number
Additional Phone
-
Area Code
Phone Number
Parent/Guardian Name
First Name
Last Name
Relationship
Cell Phone
-
Area Code
Phone Number
Additional Phone
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian's Primary Email Address
example@example.com
Emergency Contact Information
Primary Emergency Contact
First Name
Last Name
Relationship to Child/ren
Emergency Contact's Cell Phone
-
Area Code
Phone Number
Emergency Contact's Additional Phone
-
Area Code
Phone Number
Emergency Contact's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Insurance Information
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Physician Name
First Name
Last Name
Physician Phone
-
Area Code
Phone Number
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
Policy Number
Allergies/Special Health Considerations
Parent/Guardian E-Signature
Clear
Date
-
Month
-
Day
Year
Date
Photo Release
By signing below, I hereby grant Go Beyond Your Knowledge Fund (GoByk) permission to interview my child/ren and/or to use their likeness in photograph(s)/video in any and all of its publications and in any and all other media, whether now known or hereafter existing, Go Beyond Your Knowledge Fund, in perpetuity, and for other use by the organization.I will make no monetary or other claims against Go Beyond Your Knowledge Fund for the use of the interview and/or the photograph(s)/video.
Signature
Clear
Date
-
Month
-
Day
Year
Date
Summer 2023 Black History Camp
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Soulful Sounds
$
300.00
In-person camp, June 26-30, 2023
Soulful Sounds
Number of children registering
T-Shirt
Price
First Child
Youth XS
Youth S
Youth M
Youth L
Adult Sm
$
300.00
Second Child (Sibling Discount)
Youth XS
Youth S
Youth M
Youth L
Adult Sm
$
285.00
Third Child (Sibling Discount)
Youth XS
Youth S
Youth M
Youth L
Adult Sm
$
265.00
Before/After Care June 26-30, 2023
$
75.00
Drop off available at 8:00 am and pickup available by 6:00 pm
Number of children registering
Total
$
0.00
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