2021-22 Jason Taylor Virtual Reading Room Registration Form

Student Name *

First Name Middle Name Last Name
Name of School *
Please enter the name of the student's school.
Birth Date *

Month Day Year
Gender *
Student's Race
Does your child receive free or reduced priced meals?

YES NO
Is your child an ESE student?

YES NO
Name of Parent/Guardian *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail *
example@example.com
Mobile Number *
Home Number
Work Number
Emergency Contact Name *
Phone Number *
Please enter a valid phone number.
Name of Family Physician
Phone Number
Please enter a valid phone number.
Allergies and/or Medical Conditions

WAIVER/RELEASE AND ASSUMPTION OF RISK

My child/ward under the age of eighteen (18). I understand and certify that the above information is true and I authorize and release this information to the JTF for the purposes of research, monitoring of the JTRR and to seek and qualify for funds through grants. I am aware that the information is subject to verification by the Municipality, Federal Government or Grant entities that grant the funds or services used to pay and implement the JTRR program. In addition, my child/ward may participate in individual or group counseling for social skills. I understand that all JTF staff responsibilities end at six (6:30) pm. There is no supervision after six (6:30) pm. I understand that I am responsible to pick up my child/ward no later than six (6:30) pm. If I give my child/ward permission to walk home, I further understand that there will be no supervision provided.

I also do hereby knowingly, freely, and voluntarily consent to the release of all my child’s/ward’s test scores, report cards and records from the School Boards of Broward/Miami-Dade/Palm Beach County. I grant the JTF the authority to contact my child’s/ward’s principal, teacher, guidance counselor, athletic coach and any other school employee to help serve my child’s/ward’s specific educational and social needs. I grant full permission to the JTF to receive any test scores, report cards and records for the purpose of serving my child/ward.

I fully and forever release, waive and discharge the JTF, its board of directors, teachers, administrators, security personnel, staff, sponsors, third party partners and all respective shareholders, officers, directors and employees, all participating sponsors, grantors, foundations and their subsidiary corporations, any business entities in which they may have any ownership or management interest, and all persons acting by, through, under or in concert with them, or any of them (hereinafter individually or collectively referred to as “Released Parties”), from any and all liability or claims of any nature and of every kind whatsoever, known or unknown, suspected, fixed or contingent including, without limitation, liability from the negligence of the Released Parties, that I may have in the future, or that any person claiming through me may have or claim to have in the future, in connection with or resulting from my participation (or the participation of my child/ward) in the JTF, dba, JTRR but not limited to a future sponsor’s name with the Reading Room after the sponsor’s name of part of the title.

This signed statement shall serve as a release and assumption of risk for me, my heirs, executors, assigns and any business entities in which I may have any ownership of management interest, and in the event of my signature on behalf of my child/ward, the release of my child. The child’s/ward’s parents, guardians, legal representatives, heirs, executors and assigns, I also hereby agree to grant to the JTF the right to use my name/child’s/ward’s name/dependent, likeness, portrait, recorded voice and biographical material in order to advertise, promote and publicize the JTF.
Signature *

Clear
Date *

Month Day Year
Date
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