Summer Camp Detailed Registration Form

Summer Empowerment Registration

Community Service, Agriculture & Leadership
Program Details:

The 2023 Summer Empowerment Program will begin on Tuesday, June 6th, from 8 AM - 3 PM. We will host the program three days a week, Tuesdays, Wednesdays, and Thursdays. We will not meet July 4-6. The last day of the program will be Thursday, July 20th. This summer's program will focus on community service, leadership, and agriculture, enhancing youth's critical thinking, teamwork, technology, and planning skills. Snacks will be provided, but the gent will bring their lunch. Parents will be notified the day before the sponsorship if lunch is sponsored. We welcome sponsorships! The program is free you males ages 8 - 18. Our capacity for this summer is 20 gents.
Youth Information

Parents must register additional youth on a separate form.
Youth's Name*

First NameLast Name
Birth Date

MonthDayYear
Age*
Name of School*
Grade*
Will your youth be a driving or dropped off?*
Youth that drive will not be able to leave the campus without verbal consent from a parent or guardian. Youth will not be allowed to leave campus to pick up lunch and they will not be able to sit in cars at any time during the program.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number*
This field is required - enter cell phone if there is no home phone.
Cell Number*
This field is required - enter home phone if there is not cell phone.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number*
Does the youth have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Fortitude Leadership Academy, hereafter, "Fortitude", during the selected camp. In exchange for the acceptance of said child’s candidacy by Fortitude, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Fortitude 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 Fortitude, 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.

Please be advised that during meetings and sessions, youth may be photographed, videotaped, or interviewed at our location and other places during your participation in our programs. With your consent, the photograph, video or interview may be reproduced and released on our organizations website and social media platforms such as Facebook, Instagram, Twitter, etc.

I waive any right to inspect and/or approve the finished product and do release Fortitude from any liability by virtue of distortion by processing. I further agree that these items may be used for publication, broadcast or reproduction without limitation or reservation of any fee
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 {Organization} . 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.
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.
Date*

MonthDayYear
Date
Signature*

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Summer Empowerment Registration

Program Details:

Youth Information