B-RELYT's Program Registration
Section I: Student Information
Please check which B-RELYT's program you are registering for.
*
Saturday School
Summer Intensive
All Programs
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Student's Email
Address
*
Street Address
City
State / Province
Postal / Zip Code
Gender
Please Select
M
F
B
Other
Name of School you are currently attending
*
Current Grade Level Fall 2022
*
Math Class Fall 2022
*
Science Class Fall 2022
*
Extra-Curricular Activities you are currently participating in:
What are your career interests?
What would you like to learn more about?
Math
Science
Technology
Engineering
Other
If you selected other, please specify.
Section II: Parent Guardian Information
Parent Guardian 1:
Name
*
First Name
Last Name
Parent Guardian 1-Email
*
example@example.com
My address is the same as the student's address
Yes
Address
Street Address
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Parent Guardian 2
Name
First Name
Last Name
Parent Guardian 2- Email
example@example.com
My address is the same as the student's address
Yes
Address
Street Address
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Section III: Emergency Contact Information
*must be someone different than parent/guardian named above
Name
*
First Name
Last Name
Relationship
*
Emergency Contact Email
*
Cell Phone
*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Section IV: Health Insurance Information
Health Insurance Name
Member ID
Group Number
I don't have Health Insurance presently
Section V: Parental Consent for Photography and Participation in Evaluation Studies
Please indicate if you give permission for your child to participate in the following activities:
Photography
*
Yes, I give permission for my child to be photographed for B-Relyt organization, including still pictures,slides and video.
No, I do not give permission for my child to be photographed through B-Relyt
*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote B-Relyt’s mission.
Media/Photo Release
*
I give permission for my child to be photographed or videotaped as part of his/her involvement in the B-RELYT sponsored after school program. I also give permission for his/her photo and/or image to be used in publications and/or promotional material associated with the B-RELYT Program.
I do not give permission for my child to be photographed or video taped as part of his/her involvement in the B-RELYT Program. I also do not give permission for his/her photo and/or image to be used in publications and/or promotional material associated with the B-RELYT Program.
Media Release of Information:
*
Yes, I hereby give permission for my child to participate in evaluation studies of B-Relyt. This includes observations of my child doing regular activities in the program, anecdotal notes regarding his or her progress towards meeting objectives and use of developmental assessments and other evaluation results. I understand that this information would be treated confidentially and that my child’s full name will not be used on any reports of the results except for confidential reports required by the state or school district.
No I do not give my permission for my child to participate in evaluation studies for the B-Relyt organization
*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote B-Relyt’s mission.
Release and Waiver of Liability for all After School Classes and Programs
I have read RELEASE AND WAIVER OF LIABILITY FOR ALL AFTER SCHOOL CLASSES AND PROGRAMS
Yes
No
PARTICIPANT
In signing this Acknowledgement of Risk and Waiver of Liability I hereby acknowledge and represent that I am of legal age and have read this document in its entirety, understand it, and sign it voluntarily.
Date
*
-
Month
-
Day
Year
Date
Participant Signature
*
Clear
Participant Name
*
First Name
PARENT/GAURDIAN:
Participants who are under 18 years of age, or not legally competent, must sign above, and also must obtain the signature of a parent or legal guardian below: I certify that I am the parent or legal guardian of the above-named participant. On behalf of myself and my spouse, partner, co-guardian or any other person who may represent the participant, I have read the above agreement, I understand its contents, assent to its terms and conditions, and sign it of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent’s participation, and I hereby give my consent to participation by my dependent, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend B-RELYT and all B-RELYT Staff Members from and against all claims, demands or suits that my dependent has or may have.
Date
*
-
Month
-
Day
Year
Date
Parent Signature
*
Clear
Parent Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Parent Signature
Clear
Parent Name
First Name
Last Name
Submit
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