Young Debs Inc Application 2022-23

Debs and Gents Membership Registration Application 2022-2023
Which Program are you applying for (please check ONLY one) *

Debs Gents Performing Arts Outreach Only
Student Information
Student's Name *

First Name Last Name
Birth Day (MM/DD/Year) *
School's Name *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email
example@example.com
Hobbies and Interest (click all that apply) *

Reading Dance Photography Singing Acting/Theatre Sport Playing an instument Drawing/Painting Other
How did you hear about us? (Please click all that apply): *

A friend/colleague At School Attending an event Social Media (FB, IG, Twitter) Other
Parent/Guardian Information
Name *

Prefix First Name Middle Initial Last Name Suffix
Address (if different from student address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (home)
Phone Number (mobile) *
Email
example@example.com
Preferred Contact for Updates and Reminders (Please circle):
Preferred Contact for updates and reminders *

Cell phone text Email Postal Mail Other
EMERGENCY CONTACT INFORMATION

Each student must have two emergency contacts.
Emergency Contact #1 Name *

Prefix First Name Middle Initial Last Name Suffix
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (mobile) *
Phone Number (work)
Please enter a valid phone number.
Phone Number (home)
Please enter a valid phone number.
Emergency Contact #2 Name *

Prefix First Name Middle Initial Last Name Suffix
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (mobile) *
Phone Number (work)
Please enter a valid phone number.
Phone Number (home)
Please enter a valid phone number.
Membership Rules Signing this application is an indication that I, the parent/guardian and I, the student, have agreed to fully participate in the program I have applied for. This includes attending and/or actively participating in community service projects, social events, fundraising events, etiquette.

The parent and student, agree to follow the rules and regulations established by Young Debs Inc. I also agree to uphold those standards while participating in the program. I also understand that if I fail to abide by those standards, I may forfeit my participation in the program and all privileges provided by Young Debs

I, the parent, also agree to uphold the rules and regulations established by Young Debs Inc and assist in ensuring my daughter/son abides by those standards. I understand that the organization has the right to add addendums to the handbook as needed and will be notified if such changes occur.

I also confirm that all information provided in the application is true, and that falsifying any information may cause my child(ren)'s dismissal from the program. I, the parent, agree to submit all dues by the deadline. I understand all payments may be made in installments until the final deadline. A fifty dollar non-refundable payment must accompany this application in order to hold your Deb's or Gents place in the organization. The fifty dollars will be deducted from your annual dues of $450 I have read, understood and accepted the rules for participation
Signature *

Clear
Date *

Month Day Year
Date
As a parent or guardian of this student, I hereby consent to the use of photographs/videotape taken during the course of the school year for publicity, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet or other media sources I do this with full knowledge and consent and waive all claims for compensation for use, or for damages. I have read, understood and accepted the photo release form.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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Student Information

Parent/Guardian Information

EMERGENCY CONTACT INFORMATION