Student Registration Form

Registration 2024

Summer Program
Parent/Guardian Info
Name*

First NameLast Name
e-mail*
Primary Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact (If Parent/Guardian cannot be reached)*
Relationship to Student*
Emergency Phone*

Area CodePhone Number
Student Info
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Grade in School 2023-2024
Student email
Student Cell Phone

Area CodePhone Number
New or Returning Student?*

Returning StudentNew Student
Course Selection*
Donation Pledge
not required, but appreciated to help pay for meals
Add Student 2?

Add Student 2
Student 2 Info
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Grade in School 2023-2024
Student email
Student Cell Phone

Area CodePhone Number
New or Returning Student?*

Returning StudentNew Student
Each donation goes towards building IAMPurposeD Programs to help minority women and children. Our core value is to help individuals grow through what they go through.
Notes { Need to Know about my child}:
Terms and Conditions
Today's Date

MonthDayYear
Date
By checking 'I Agree' below and submitting this form, you, the Parent or Guardian of the above student(s), agree to release "IAMPurposeD", including instructors and assistants from liability for any and all injuries which may occur while training, practicing, performing, or during any event or activity. You also agree that you are responsible for health and accident insurance and any medical costs incurred due to injury. You give permission for emergency medical transportation and treatment of your student(s) at your expense should the need arise. You also give your permission for the public display of any visual images that your child may appear in.
I Agree
Should be Empty:

Registration 2024

Parent/Guardian Info

Student Info

Student 2 Info

Terms and Conditions