Thrive Fall Zoom Registration Form

THRIVE 4 Day RESILIENCE CAMP

Student Registration Form
Please indicate the method of participation*

Elementary School 4:00-5:00pmMiddle & High School 5:00-6:00pm
Student Name*

First NameMiddle NameLast Name
Age
Gender*
School*
Other School
Grade*
Race/Ethnicity*
Hold Ctrl to select more than 1 race/ethnicity
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Parent/Guardian Information
Name*

First NameLast Name
Relationship*
Email
Cell Number*
Home Number
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship*
Waivers and Release
CANCELLATION POLICY: Shefa Life Inc. reserves the right to cancel any program due to insufficient enrollment.

CLASS CONDUCT: Shefa Life Inc. reserves the right to release any child who is not a good fit for the class and/or behaviors become unmanageable. Parents will receive verbal and/or written warnings. No children will be allowed to intentionally verbally/physically harm any other person while class is in session.

WAIVER OF LIABILITY: In consideration of being permitted to Shefa Life Inc. programs, on behalf of myself, my family, my heirs, and my assigns, I hereby release Shefa Life Inc., PPEP, Inc. its agents, and its employees from liability for injury, loss, or death to the above-mentioned participant while using any facility or equipment or in any way associated with participating in the Shefa Life Inc. program now or in the future.
Informed Consent and Acknowledgement
I hereby give my approval for my child’s participation in any and all activities prepared by Shefa Life Inc. during the session. The session content and all relevant materials related to the student will be held confidential unless the student is at risk to hurt themselves or someone else. I give permission to Shefa Life Inc. to photograph my child's artwork created during art sessions.

My child's participation is voluntary. I understand that the selected activities may involve accidental injury and hereby voluntarily assume such risks. Knowing these risks, I want my child to participate in this activity. I (on behalf of my child) hereby assume the risk, and hereby waive, release, and discharge Shefa Life Inc., PPEP, Inc, its officers, employees, activity instructors and assistants, and all officers and employees of the school or community center sites where said activity will take place, for any and all claims for damages for personal injuries, or claims for damages to property, which my child or my child's heirs, assigns, executors or administrators may have or which may accrue to my child's participation in this activity. I have read the above and understand important legal rights are being waived.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
The Thrive Program is a component of the Trauma Informed Prevention Program funded by the Arizona Governor’s Office of Youth Faith and Family Substance Abuse Block Grant through Portable Practical Educational Preparation (PPEP), Inc. and in partnership with Shefa Life, Inc.
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THRIVE 4 Day RESILIENCE CAMP

Parent/Guardian Information

Emergency Contact Information

Waivers and Release

Informed Consent and Acknowledgement