StudentSignUpForm

STUDENT DETAILS:

Enrollment form for students interested in the I CAN Program.
Students Name:*

First NameLast Name
Students Age*
Students Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN

Contact information:
Guardian/Sponsors Name:*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Address (if different from student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION

In case of emergency, if primary guardian listed above is not reachable.
Name*

First NameLast Name
Relation to student:*
Emergency Contact Phone Number:*
Please enter a valid phone number.
PARENTAL/GUARDIAN WAIVER

Parents/Guardians must read, understand, sign and review with potential students all subjects from this agreement.
A. Section

Terms
NOTE:

*This Participation Agreement/Assumption of Risk Liability Release and Indemnification must be signed and on-file with "I CAN" Program as a condition precedent for attending our free after school skateboarding program.

*By providing an e-mail address you agree to receive promotional and special event notice via email. Your email address will not be provided to third parties, it will be used only to provide you with the "I CAN" Program updates and information.

*The Participation Agreement must be submitted before allowed to participate in the "I CAN" Program.
I verify that I have read and understand the above statement*

Yes
B. Section

Assumption of Risk
The "I CAN" Program PARTICIPATION AGREEMENT ASSUMPTION OF RISK, LIABILITY AND INDEMNIFICATION FOR PARTICIPANT:

PARTICIPANTS/PARENTS (if participant is 17 years of age or younger): Please read (or help your child read) and understand the following: I understand:

1). There are certain dangers, risks, and hazards inherent in participation in skateboarding including but not limited to falling and /or colliding with fixed or moveable structures and/or participants;

2). Conditions may become more hazardous or dangerous during the use of the Skate Park due to changes in weather, temperature, the actions of others, and/or other changes in circumstances;

3). The potential consequences of using a Skate Park include, but are not limited to, the possibility of property damage and/or bodily injury. This includes death, permanent disability, and other serious bodily injuries.

4). The "I CAN" Program provides and requires participants to wear certain protective equipment during skate classes.
I verify that I have read and understand the above statement*

Yes
C. Section

Release of Liability agreement
I AGREE:

1). The "I CAN" Program name, instructors, and representatives shall not be:

Liable to me for any damage or injury, whatsoever, to person or property arising out of or in connection with my use of, or presence of The "I CAN" Program Skate classes.

2). Students and Guardians have the right to:

Refuse any participation in activities considered dangerous or potentially hazardous.

Inform The "I CAN" Program associates of any activity that may be considered dangerous or potentially hazardous.
I verify that I have read and understand the above statement*

Yes
D. Section

Signature agreement
Parents/Guardians; BY SIGNING BELOW YOU HEREBY CERTIFY THAT:

1). YOU have reviewed the above with my child and that he/she understands his/her risks and responsibilities as a student of The "I CAN" after school skateboarding program.

2). YOU and YOUR STUDENT fully understand and acknowledge said risks and responsibilities, hereby grant permission for my minor child to participate in The "I CAN" Program skate lessons and activities.

YOU hereby knowingly and voluntarily agree, on behalf of themselves and their heirs, successors, and assigns to:

- Assume responsibility for all risks of loss, damage, or injury (including but not limited to disability and/or death) that may be sustained by participants or participant's property, which may arise out of, result from, or be associated use of The "I can" Program services.

- Forever release and discharge The "I CAN" Program, and all of its agents, officers, employees, and representatives from liability for any and all bodily injury (including but not limited to disability and/or death), property damage, and/or other loss whatsoever which may arise out of, result from directly or indirectly, or be associated with participant's use of, or presence of "I CAN" Program services.

- This release/indemnification is to be interpreted in its broadest legal sense to protect "I CAN" Program and any of its affiliates, agents, officers or representatives.
I verify that I have read and understand the above statement*

Yes
E. Section

Media release and use agreement
PHOTOGRAPHY/VIDEOGRAPHY RELEASE:

By signing, YOU hereby give the "I CAN" Program unrestricted permission and absolute right to take, use YOUR STUDENT'S:

- Name, testimonial, biographical data and/or publish, reproduce, edit, exhibit, project, display and/or copyright photographic images or pictures of me or my child(ren), whether still, single, multiple, or moving, or in which I (they) may be included in whole or in part, in color or otherwise, through any form of media (print, digital, electronic, broadcast or otherwise) at any clinic or elsewhere, for art, advertising, recruitment, marketing, fund raising, publicity, archival or any other lawful purpose.
I verify that I have read and understand the above statement*

Yes
By signing you agree to the terms stated in ALL sections stated above. This releases all liability and grants all rights to Ondeck Alliance and any partner organizations.*

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STUDENT DETAILS:

PARENT/GUARDIAN

EMERGENCY CONTACT INFORMATION

PARENTAL/GUARDIAN WAIVER

A. Section

B. Section

C. Section

D. Section

E. Section