Coda Revive Application
Coda’s newest program is a journey to “Life that Works”. Find your incredible worth and true identity in Christ - moving from a feeling of meaninglessness to a purpose driven life full of love, service and adventure! Join us for four days of camp with amazing storyteller Michael Douglas followed by a weekly Christian youth program at New River Coda. Grades 5th - 12th welcome. Free, fun and meaningful!
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
5th
6th
7th
8th
9th
10th
11th
12th
Student Ethnicity
*
Please Select
Caucasian
African-American
Asian/Pacific Islander
Hispanic
Native American
Multi-Ethnicity
Other
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
Other
T-Shirt Size
Please Select
YS
YM
YL
YXL
XS
S
M
L
XL
XXL
Parent/Guardian 1
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First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Parent/Guardian 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Terms & Policies
Liability Waiver: I am aware that my child will be exposed to others including but not limited to Coda staff, students, interns, teachers and volunteers. In the chance that my child is exposed to COVID-19 or any other contagious disease, there is a risk of illness, permanent disability, and even death. In the event that any issue listed above were to occur, I agree to not sue nor seek any legal action, neither would Coda Mountain Academy, supervisors, staff, volunteers, interns, nor teachers will be held accountable.
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I understand and acknowledge the liability waiver written above and that Coda Mountain Academy nor any supervisor, staff, volunteer, intern nor teacher will be held accountable for the risk of exposure to COVID-19 or any other liabilities.
Signature
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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 use.
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I, parent or guardian, consent to the above stated photo/video waiver for Coda.
I, parent or guardian, DO NOT consent to the above stated photo/video waiver for Coda.
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
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Phone Number
*
Please enter a valid phone number.
Relationship to student
*
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. In the event of injury, accident, illness or other emergency while participating in the after-school 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 Esther Morey, Savannah Peters, Perri Kiser, Claire McGrew, or an associated adult supervisor 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. I further authorize disclosure of medical information by a treating physician to Esther Morey, Savannah Peters, Perri Kiser, Claire McGrew, or associated adult supervisor as permitted by The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Submit
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