Student Registration Form

Student's Name

First NameLast Name

Birth Date

MonthDayYear

Grade (2nd - 6th only)

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Cell Number

Home Number

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Lena's Learners Academy LLC during your child's YEAR Long session. In exchange for the acceptance of said child’s candidacy by Lena's Learners Academy LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Lena's Learners Academy LLC, 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 when offered.

In case of injury to said child, I hereby waive all claims against Lena's Learners Academy LLC, including all staff 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 activities if and when performed, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Media

I understand that Lena's Learners Academy LLC reserves the right to use, in any or all social media, publications, promotional materials and publicity, any photograph, audiotape, videotape or film in which the student (child) appears. In the event, the parent/guardian does not want the student (child) to appear in any media mentioned above in connection with Lena's Learners Academy LLC:

Please respond here if you do not agree to having your child photographed*

No

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Medical Release and Authorization

As Parent and/or Guardian of the named student, 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 student. 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 Lena's Learners Academy LLC, and its affiliates including Directors, Instructors, Coaches, and Camp 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.

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.

Signature

Date

E-mail

example@example.com

Registration Form

Student Information