Ivy Elite Youth Registration Form

Ivy Elite Youth Member Application

Year-Round Intake | Ivy Elite 501c3 Nonprofit and Trademark Organization
Please complete the form for each scholar in your house hold attending.
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

FemaleMale
Age (must be between 4 - 18 as of 01/01/2023).
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Emergency Contact #1

First NameLast Name
Phone Number
Please enter a valid phone number.
Emergency Contact #2

First NameLast Name
Phone Number
Please enter a valid phone number.
Select Program

MentoringBehavior InterventionAcademic Saturday Intervention1:1 TutoringK-12 Group TutoringElite Scholars AcademyEmpower318Performing Arts - Dance, Cheer, and Theatre
Youth Development (select up 2 to extracurricular programming)

FootballBasketballCheerPerforming Arts - DanceSoccerTrack and Field
Elementary/Middle/High School
Leadership Academy (select one location)

Monroe, LABaton Rouge, LA
School Grade/Classification (age must be between 11-18 as of 01/01/2023).

Kindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
T-shirt size
Please read and accept terms and conditions (by checking) each of the following:*

I give my informed consent and permission for my son/daughter to participate in the Ivy Elite and its related activities, such Mentoring, Elite Scholars Academy, Empower318, and/or Performing Arts.I agree to have my child follow all Ivy Elite guidelines and understand that any violation on my son’s/daughter’s part may result in suspension and/or termination of the mentoring, performing arts, and/or elite scholar’s academy relationship.I hereby acknowledge that son/daughter will not be transported by his/her mentor and/or Ivy Elite staff or representatives while participating in the program, and that such transportation is voluntary and at his/her and parent/legal guardian on risk.I release the Ivy Elite staff or its representatives of all liability of injury, death, or other damage to me, my son/daughter, family, estate, or heirs that may result from his/her participation in the project, including but not limited to transportation, and hold harmless any Ivy Elite mentor, volunteer, project staff, board member, or its representatives, both collectively and individually, of any injury, physical, emotional, and/or mental.I agree to allow Ivy Elite to use photographic image or name of my son/daughter taken while participating in the mentoring, elite scholar’s academy, and/or performing arts program. These images will be used in student awards, member spotlight, promotions or related marketing materials.I do hereby authorize Ashley Nash and/or any designated representative of Ivy Elite Incorporated to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. I further understand that I am responsible for any medical expenses and that the absence of health insurance does not make Ivy Elite Incorporated responsible for payment of medical expenses.I acknowledge my responsibility of paying in full monthly tuition, any associated costume fees, recital fees, athletic leadership, minimal required Ad fees, transportation, entry fees, parade fees, venue fees, registration fees, travel expenses for performance and all other communicated cost involved and that I will be fully obligated to pay unless a 30-day written notification is given prior to child being withdrawn from the program.I hereby acknowledge that my child or myself WILL NOT transported by my/his/her mentor and/or Ivy Elite staff or representatives while participating in the program, and that such transportation is voluntary and at my/his/her own risk.I agree to have my child or myself follow all mentoring project guidelines and understand that any violation on my child’s or myself part may result in suspension and/or termination of the mentoring relationship.understand that risk of injury is possible in any physical activity and I, on the behalf of myself and/or my child, knowingly and voluntarily accept that risk.It is understood that the above-mentioned student is in good health and is physically capable of participating in the instruction, activities, programs, and practices of Ivy Elite Incorporated.I agree on behalf of my child or myself to adhere to all rules and regulations of, Ivy Elite Incorporated.I agree to receive and invoice for my child’s participation through QuickBooks, all payments can be made through CashApp to PayPal.
This Release of Liability, Assumption of Risk and Hold Harmless Agreement is made effective as of ______________ (Date) by between Ivy Elite Incorporated. A nonprofit organization, and the undersigned parent or legal guardian of the above-named child. By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Date of Agreement with Parent or Guardian

MonthDayYear
Date
Signature | Parent/ Guardian (Print Name)

First NameLast Name
Signature

Clear
Should be Empty:

Ivy Elite Youth Member Application