The "X" for Boys Program Application: Spring 2023

The "X" for Boys Program Application: Spring 2023

Welcome to the official application to The X for Boys Program based in Albany, GA! We appreciate your interest in enrolling your son(s) in our program. To be eligible for acceptance, a parent must complete and submit this application and young men must be between the ages of 11-17 as of January 1, 2023. Young men must also live in the Albany, GA area or within a 20 mile radius to downtown Albany, GA. Additionally, The X for Boys program is FREE for all eligible boys. Once your application is submitted, someone from our office will contact you with next steps within 3-5 business days. Please be sure to enter your information correctly and carefully, as we do not want to miss your application submission or not be able to contact you. Thank you!
Student's First Name*
Student’s Last Name*
Student's Middle Initial
Student's Current Age*
Date of Birth*

MonthDayYear
Date
Student's Grade in School*

4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
What School Does He Currently Attend?*
Is your son a returning X Participant?*

YesNo
Home Address*

Home Address

Street Address Line 2

CityState

Zip
Parent/Guardian First and Last Name*
Parent/Guardian E-mail Address*
example@example.com
Home Phone
Work Phone
Cell Phone*
May We Text You?*

YesNo
Emergency Contact First/Last Name*
Emergency Contact Phone Number*
Relation to Student*
Please list any food or other types of allergies the student has.*
Does the student require use of an epipen?*

YesNo
If yes, does the student know how to self-administer their epipen?

YesNo
Please provide any details or comments about why you want your son to be apart of our organization. (Include any behavioral or disciplinary issues that may help us better serve you).
Student's T-Shirt Size*

Youth LargeAdult SmallAdult MediumAdult LargeAdult XLargeAdult 2XLargeAdult 3XLarge
Sessions are typically in the evenings from 6PM until 730PM, are you able to drop off and pick up your son for sessions?*

YesNo
Would you be interested in helping other parents carpool?*

YesNo
Are you interested in helping volunteer for our program?*

YesNo
Do you have the ability to download and use the Band.us app? That is our main medium of communication and will be hard for your son to participate without a parent in the Band app.*

YesNo
Media Release

Please read and accept the following statement.
I hereby grant The X for Boys to release my child’s likeness to the local media outlets, allowed by The X for Boys, to identify the appropriate media and release the information about my child’s participation as a student (we typically keep their names confidential).*

I Accept
Liability Waiver and Consent for Treatment

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that the parent or guardian of the above-named student (1) understand that your child's participation as a student shall refer to any travel, workshop/curricula, or event within the active academic year, (2) do hereby understand that the nature of your child's participation as a student, and you release The X for Boys to include all unintentional injuries sustained during your child's participation as a student, (3) do consent to emergency medical treatment in the event of such an emergency, given that emergency contacts cannot be reached, (4) understand that The X for Boys does not provide insurance for student's and any bill incurred due to emergency treatment will be your responsibility. You also certify that you are covered by insurance that will cover any treatment caused by injury and if not that you are solely responsible for payment and any bill incurred due to emergency treatment and that yourself and/or your insurance company only are responsible for payment of such treatment. (5) and that you certify that the above information is true and accurate.*

I Accept
COVID-19 Acknowledgement/Liability Waiver

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that the above-named student is participating in The X for Boys Program voluntarily. If the student shows any signs of COVID-19 illness, such as a cough, sore throat, or a temperature above 100.4, you will keep the student at home and contact The X for Boys immediately. IFurther, you understand that if the student is in the care of The X for Boys and begins to show any signs of COVID-19, you will be contacted immediately and expected to pick up your child immediately. A student who becomes sick must either follow the latest recommendations published by the CDC or provide The X for Boys with a negative COVID-19 test. If one of the other students or staff group tests positive for COVID-19, you will be contacted immediately with instruction. Students may receive a temperature check and be asked a series of questions about COVID-19 risks before various The X for Boys functions.*

I Accept
Waiver of Liability Relating to COronavirus/COVID-19

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that you have read and accept the following statement. The novel coronavirus, COVID-19, has been declared a worldwide pandemic. COVID-19 is extremely contagious. Every individual faces risks of infection from the virus, whether at work, at home or engaged in activities away from work. This guidance is an effort to share information. The below considerations should be followed as is reasonable under the given circumstances and re-evaluated as new orders and advisories are introduced through public health officials, and governmental agencies. The virus is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and through the air. People can be infected and show no symptoms but still spread the disease. There is no known treatment or cure, however vaccinations have begun being administered for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life-threatening illness and even death. Even though steps are being implemented to reduce the risk of transmission, The X for Boys cannot prevent your child from being exposed to, contracting, or spreading COVID-19 if you decide your child will participate. It is not possible to eliminate the risk of contracting the disease. Therefore, if you choose for your child to participate, you may be exposing your child, your family, and others to a risk of contracting or spreading COVID-19.*

I Accept
Assumption of Risk

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that you have read and accept the following statement. I understand the above warning concerning COVID-19. I hereby choose to accept the risk that my child may contract COVID-19 while engaging in school athletic activities. I further accept the risk that, if my child contracts COVID-19, that he or she may spread the virus to others he or she comes in contact with, including familymembers. I accept these risks because I want my child to participate in The X for Boys Program.*

I Accept
Waiver of Lawsuit/Liability

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that you have read and accept the following statement. I hereby forever release and waive on behalf of myself, my heirs, executors or assigns any right to bring suit for myself or on behalf of my child against The X for Boys and its administrators, teachers, officials, agents, employees, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to participation in The X for Boys organization. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease, or any other loss I may have to seek damages, whether known or unknown, foreseen or unforeseen.*

I Accept
Choice of Law

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that you have read and accept the following statement. I understand that the law of the State of Georgia will apply to this contract. I HAVE CAREFULLY READ AND UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUM THE RISK ON BEHALF OF MYSELF AND MY CHILD AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE.*

I Accept
General Risk of Injury

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that you have read and accept the following statement. I acknowledge and understand that there is risk of injury involved in various situations. I understand that the students will be under the supervision and direction of The X for Boys. I agree to follow the rules and instructions of The X for Boys in order to reduce the risk of injury to the student and others. However, I acknowledge and understand that The X for Boys cannot eliminate the risk of general injury. Injuries may and do occur. Injuries can be severe and, in some cases, may result in permanent disability or even death. I freely, knowingly, and willfully accept and assume the risk of injury that might occur from participation in The X for Boys.*

I Accept
Hold Harmless Agreement

Please read and accept the following statement.
By selecting "I Accept," you acknowledge that you have read and accept the following statement. As a lawful parent/guardian of the above-named student, I hereby give permission for my child to participate in The X for Boys sponsored extra-curricular activities. I agree that I have fully read, understand, and agree to the conditions set forth below, and submit such choice as a binding signature of agreement: I acknowledge and agree that, during The X for Boys sponsored activities, my child will be subject to any and all The X for Boys disciplinary rules and Student Code of Conduct to which he is subject during the school day. I further understand that my child will be subject to the supervision and direction of those who accompany the students on behalf of The X for Boys. I consent for/to my child's participation in extra-curricular activities. I acknowledge and agree that I am responsible for informing appropriate school personnel of any medical actions they believe necessary for my child until such time as I may be contacted. I acknowledge and agree that The X for Boys, its officers, employees, agents and volunteers do not have or assume any liability for damages, losses, or injuries to the above-named student as a result of the student participating in this activity. I acknowledge and agree that any revocation permission given by this form can only be in writing and must be delivered to the appropriate school officials to be effective.*

I Accept
This student information profile is complete and accurate to the best of my knowledge. The X For Boys staff in charge may give permission to the physician selected to order x-rays, routine tests, and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by The X for Boys to hospitalize, secure proper treatment for, and to order injection and/or surgery for my child as named above.
Parent Signature*

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Date*

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The "X" for Boys Program Application: Spring 2023

Media Release

Liability Waiver and Consent for Treatment

COVID-19 Acknowledgement/Liability Waiver

Waiver of Liability Relating to COronavirus/COVID-19

Assumption of Risk

Waiver of Lawsuit/Liability

Choice of Law

General Risk of Injury

Hold Harmless Agreement