Coda Revive Registration
Please complete this form to register your child for Coda Revive. We need each child to have a completed photo waiver and liability waiver on file with us. Coda Revive is a Christian non-denominational group in which youth can explore or strengthen their faith. Regular Revive meetings happen on Tuesdays from 6:45-8:30 PM at the New River Coda Center, 270 Elizabeth Way (across Hwy 19 from MedExpress...the brown building next to New River Baptist Church). Students in 4th-12th grade are welcome to attend!
Student Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Student Age
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Student Grade
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Please Select
4th
5th
6th
7th
8th
9th
10th
11th
12th
Student Gender
*
Please Select
Male
Female
Parent Email
example@example.com
School
*
Please Select
Fayetteville-PK8
Ansted Elem
Divide Elem
New River Primary
New River Int.
Meadow Bridge Elem
Gauley Bridge Elem
Valley-PK8
Oak Hill Middle
Oak Hill High
Midland Trail High
Meadow Bridge High
Homeschool
Other
Parent/Guardian 1
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First Name
Last Name
Parent/Guardian 1 Phone Number
*
Please enter a valid phone number.
Text Consent 1: Do you consent to receive text messages at this phone number? We send a text in events of cancellations, emergencies, and announcements. If you don't want to receive text messages from us, you will only receive this information via email if you provided us with a valid email address.
*
Yes
No
Parent/Guardian 2
First Name
Last Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Text Consent 2: Do you consent to receive text messages at this phone number? We send a text in events of cancellations, emergencies, and announcements. If you don't want to receive text messages from us, you will only receive this information via email if you provided us with a valid email address.
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Terms & Policies
Communication: GroupMe
We send all weekly updates and communication through an app called GroupMe. Please download the app and check it for information regularly. We will add your phone number to the Revive Youth group.
I understand that GroupMe is the main way that information is communicated, and my phone number will be added to the Revive Youth group.
Photo Waiver
Understanding that Coda photos and videos are important to promote public awareness, access future scholarship funding and reach more youth, I hereby consent for my child (or myself if 18 or older) to be photographed and/or videoed for Coda Mountain Academy. The resulting photographs or videos may be subsequently used without compensation to me by Coda Mountain Academy, or third parties for publications (including web sites,) advertising, facebook and/or publicity purposes at the discretion of Coda Mountain Academy. Some photos and videos will be used in the year end grant report. I waive the right to inspect or approve the finished photograph, video and/or publication.
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I, parent or guardian, consent to the above stated photo/video waiver for Coda Revive.
I, parent or guardian, DO NOT consent to the above stated photo/video waiver for Coda Revive.
Medical Release
Food Allergies
*
Drug Allergies
*
Any medical problems and/or medications that we should be aware of:
Emergency Contact- this is who we will contact if we cannot reach Parent/Guardian 1 or Parent/Guardian 2
*
Phone Number
*
Please enter a valid phone number.
Relationship to student
*
Liability Release Form
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I, the undersigned, am the parent or legal guardian of this minor and have given my consent for him/her to participate in activities hosted by Coda Mountain Academy, and agree to hold Coda Mountain Academy free and harmless of claims in the event of injury, accident, illness, or other emergency. In the event of injury, accident, illness or other emergency while participating in this Coda program, I consent to any reasonable medical treatment as deemed necessary by a licensed physician, emergency medical technicians, nurses, and laboratory technicians. In the event any treatment is required, which a physician and/or hospital personnel refuses to administer without my consent, I hereby authorize a Coda associated adult to give such consent for me, if I cannot be reached by telephone at one of the numbers listed above, or because of an emergency in which there is no time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for me, I agree to hold such person, other associated adults and Coda Mountain Academy free and harmless of claims, demands, or suits for damages which may arise from the giving of such consent. I also acknowledge that I accept to be ultimately responsible for the cost of any medical care whether or not the cost of that medical care will be reimbursed by my health insurance provider.
Signature
Submit
Should be Empty: