You can always press Enter⏎ to continue
articleCreated with Sketch.
2022 SWISH for SUCESS Detailed Registration Form
Form used to gather information about the students that are going to join the program activities this summer. 
articleCreated with Sketch.
  • 1

    Athlete Information

    Press
    Enter
  • 2
    Press
    Enter
  • 3
    -
    Pick a Date
    Press
    Enter
  • 4
    United States
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 5
    NOTE: Transportation is not covered by scholarship.
    Press
    Enter
  • 6
    Please enter Explore Schools Network or Launch Charter School
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Press
    Enter
  • 9
    NOTE: Scholarship covers only one (1) camp shirt. Additional Shirts Cost $10
    • Youth Small
    • Youth Medium
    • Youth Large
    • Youth X-Large
    • Adult Small
    • Adult Medium
    • Adult Large
    • Adult X-Large
    Press
    Enter
  • 10
    NOTE: Scholarship covers only one (1) camp shirt. You can order up to five (5) shirts.
    • 1
    • 2
    • 3
    • 4
    • 5
    Press
    Enter
  • 11

    Parent/Guardian Information

    Press
    Enter
  • 12
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Press
    Enter
  • 15
    Email Verified

    The verification code has been sent to some@email.com
    Please check your mailbox and paste the code below to complete verification

    Didn't receive verification code? or
    Receiving the email may take a few minutes, thank you for your patience!
    Press
    Enter
  • 16

    Emergency Information

    Press
    Enter
  • 17
    Press
    Enter
  • 18
    • Mother
    • Father
    • Grandparent
    • Aunt
    • Uncle
    • Sibling
    • Babysitter/Nanny
    • Other
    Press
    Enter
  • 19
    Press
    Enter
  • 20
    Press
    Enter
  • 21
    NOTE: Type N/A if service is not required.
    Press
    Enter
  • 22
    Press
    Enter
  • 23
    Press
    Enter
  • 24

    Informed Consent and Acknowledgement

    I hereby give my approval for my child’s participation in any and all activities prepared by SWISH United, Inc., during the selected camp. In exchange for the acceptance of said child’s candidacy by SWISH United, Inc., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless SWISH United, Inc. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

    In case of injury to said child, I hereby waive all claims against SWISH United, Inc. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

    Press
    Enter
  • 25

    Medical Release and Authorization

    As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

    Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

    Permission is also granted to the SWISH United, Inc. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

    Release authorized on the dates and/or duration of the registered season.

    This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

    Press
    Enter
  • 26

    RELEASE FOR PUBLICITY PURPOSES

    I hereby authorize SWISH United, Inc. and any program under its umbrella to publish the photographs or video taken of me and/or the undersigned minor children, and our names, for use on the SWISH website (www.swishacademy.org) and any social media platforms. I release SWISH United, Inc. and any program under its umbrella from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the child(ren) registered and that I have the authority to authorize SWISH United, Inc. and any program under its umbrella to use their photographs, videos and names. I acknowledge that since participation in publications, social media platforms and websites produced by SWISH United, Inc. and any program under its umbrella is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication, social media platforms and website produced by SWISH United, Inc. and any program under its umbrella, confers no rights of ownership whatsoever. I release SWISH United, Inc. and any program under its umbrella, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.

    Press
    Enter
  • 27
    Press
    Enter
  • 28

    Make money order payable to SWISH United, Inc. (Must be received by 6/15/2022)

    Mail to 40 Graham Street Suite #2 Jersey City, NJ 07307

    Press
    Enter
  • 29

    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.

    Press
    Enter
  • 30
    Clear
    Press
    Enter
  • 31
    prevnext( X )
      My Bag
      0
      My Bag
      Great Product Name
      $20
      Quantity:1
      Size:Small
      RemoveEdit
      Great Product Name
      $20
      Quantity:1
      Size:Small
      RemoveEdit
      Great Product Name
      $20
      Quantity:1
      Size:Small
      RemoveEdit
      Great Product Name
      $20
      Quantity:1
      Size:Small
      RemoveEdit
      ORDER SUMMARY
      Total costUSD
      • SWISH FOR SUCCESS SUMMER ENRICHMENT
        $1,700.00+RemoveEdit
        Back
        Total cost $0.00
        My Products
        loading smart payment buttons...
        The payment is ready! It will be completed once you submit the form.
        Press
        Enter
      • Should be Empty:
      JotForm Logo
      Now create your own Jotform - It's free!Create your own Jotform
      Question Label
      1 of 31See AllGo Back
      close