Summer Youth Registration form
Thank you for registering your daughter for Straight Talk 4 Teen Girls Summer Sessions. Our sessions are on Saturdays and some will take place during the week. You will receive a list of events for your child to attend. Summer Sessions start July 17th-July 20th for Girls. August 7th-10th for the boys ages 12-17. There will be a $25 registration fee plus a donation of $75 for youth outside of the City of Richmond.
Child’s Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child Phone Number ( if applicable)
-
Area Code
Phone Number
Childs E-mail
Back
Next
School attending in the Fall 2023
Grade level in the Fall 2023
*
Which School will your child attend in the fall?
*
School ( Student) ID Number (required)
*
Yes
No
N/A
Gender
Female
Male
Non-binary
Race
American Indian/Alaskan Native
Black
White
Hawaiian/Latino
Has your child's school identified your child as an English Language Learner?
Yes
No
Parent/Guardian #1
Name (First Name,Last Name)
Relationship to youth
Preferred Language for Communication
Work Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Relationship to Youth
Preferred Language for Communication?
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Mobile Phone Number
-
Area Code
Phone Number
Back
Next
Household IncomeWe ask for this information to get a better understanding of the families we serve and to ensure that resources are equitably distributed across the City of Richmond. Your personal information will not be reported. Total Household Income? Please type in one range.Less than $10,000 $10,000 to $19,999 $20,000 to $29,999 $30,000 to $39,999$40,000 to $49,999 $50,000 to $59,000 $60,000 to $69,999 $70,000 to $79,999$80,000 to $89,999 $90,000 to $99,999 $100,000 to $149,000 $150,000 or more
Total Number of Children in Household
Total Number of Adults in Household (Over 18 years of Age)
Medicine needed during program hours?
Yes
No
If yes, please list medications and dosages here:
Allergies
Yes
No
If yes, please list allergies here:
Does your child have any special needs that we should know about?
Yes
No
If yes, please explain:
Is there anything else that you like the program staff to know about your child?
Accommodations
Who is allowed to pick up your child?
Medical & Photo Release Form.. It is recommended that participants secure adequate medical insurance to cover any injuries that may arise from participation in A Better Day Than Yesterday Initiative Programs( ABDTYIP). I hereby approve myself and/or my child’s participation in the program. I hereby consent to emergency medical treatment for my child on my behalf. In addition, I will assume any and all financial responsibility. To the best of my knowledge, there are no physical and/or other conditions, which would interfere with my child’s participation in such activities .I, the undersigned, hereby release A Better Day Than Yesterday Initiative Program from any liability or claims for injury, illness, or property damage that I sustain and/or cause during my participation, or sustained by my son/daughter/minor in my care participating in this event, program or other which is in any way related. I expressly accept and assume all of the risk inherent in this activity or that might have been caused by the negligence of Releases. Releases are defined as partners, sponsors, officers, members, agents, employees and any other organization, entities, and individuals who are serving A Better Day Than Yesterday Initiative Program including all volunteers assisting with programs, events or other ABDTYIP activities. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Release from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional misconduct. PHOTO RELEASE: I hereby give consent for ABDTYIP, to use photographs and/or videos of my minor child, to be used in its publications, including its website and/or social media. I release A Better Day Than Yesterday Initiative Program LLC. From any expectation of confidentiality or financial reimbursement on behalf of the aforementioned minor child and/or myself. Child Disclaimer and Signature: I certify that my answers are true and complete to the best of my knowledge.
Agree
Disagree
STUDENT/GROUP TRAVEL WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT FOR 1. In consideration for receiving permission of A Better Day Than Yesterday Initiative Program/Child Advocacy Mentoring Program, to participate in the (Weekend Retreat with A Better Day Than Yesterday Initiative Program/Child Advocacy Mentoring Program), I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE ,A Better Day Than Yesterday Initiative Program/Child Advocacy Mentoring Program, Their officers, agents, servants, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted.2. I am fully aware of the risks involved and hazards connected to this activity, including but not limited to travel risks. I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such an activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise.3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.4. I understand that A Better Day Than Yesterday Initiative Program/Child Advocacy Mentoring Program,does not maintain any medical or health insurance policies for Youth/Adults other than the Personal Accident Insurance provided by A Better Day Than Yesterday Initiative Program/Child Advocacy Mentoring Program, contract rental insurance covering any circumstances arising from my participation in this event or any activity associated with or facilitating that participation. As such, I am aware that I should review my personal insurance portfolio, especially accident/medical coverages.5. It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless agreement shall be construed in accordance with the laws of the State of Virginia.6. IN SIGNING/Agreeing to THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.
Please Select
I Agree
I Don't agree
COVID - 19 Release I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that ABDTYIP has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that ABDTYIP can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families. I hereby release and agree to hold ABDTYIP harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from ABDTYIP. I understand that this release discharges ABDTYIP from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from ABDTYIP. This liability waiver and release extends to the salon together with all owners, partners, and employees.
*
I Agree
I Disagree
Signature
Submit Form
Should be Empty: