MARINE AND HOSPITALITY VOCATIONAL PROGRAM

Participant Name:*

First NameMiddle NameLast Name

Parent or Guardian 1 Name:*

First NameLast Name

Parent or Guardian 2 Name:

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email:*

Phone Number:*

Area CodePhone Number

Emergency Contact Name 1 (Non-Parent):*

First NameLast Name

Emergency Contact Number (Non -Parent):*

Area CodePhone Number

Emergency Contact Name 2 (Non-Parent):*

First NameLast Name

Emergency Contact Number (Non-Parent):*

Area CodePhone Number

Gender:*

MaleFemaleOther

Ethnicity:*

Are you proficient in English?*

YesNo

Do you Speak Any Other Language(s):*

SpanishHaitian-CreoleOtherNone

Participant's Date of Birth:*

Date

Participant's Shirt Size:*

Can You Swim?*

YesNo

List Any Accommodations Needed:*

Do you have a documented disability?

If Yes, Best Clarify the Type (Check all that Apply):*

What ways do you communicate best:*

Speaks and is easily understoodSpeaks but is difficult to understandUses communication devices like pictures or a boardUses sign languageUses gestures or expressions like pointing, pulling, etc.Uses sounds that are not words like laughing, crying, etc.

Which job skills interest you the most*

Are you on any Medications? If so, Please Specify:*

Please Note Any Allergies:*

Notes/Conditions:*

Waiver

I hereby waive any privacy or other privilege I might have to authorize the Federal Bureau of Investigations to check my name in its criminal records, and if there are any entries to therein copy such and deliver copies of any such entries or other references to Shake-A-Leg Miami. The waiver is executed with full knowledge and understanding that the information is for the use of Shake-A-Leg Miami in evaluating my application for membership in the organization, particularly my worthiness of character as an influence on young persons I may come in contact with as a member of Shake-A-Leg Miami.

In consideration of Shake-A-Leg Miami, Inc. extending to me the privilege of participating in its water sports program, I fully assume all risks and waive all liability in connection with my participation in any program, and in particular, without limitation, to the extent permitted by law, I and my heirs, representatives, executors, or administrators and my undersigned parent, guardian or aide (if applicable) remise, release, indemnify, acquit and hold harmless and forever discharge Shake-A-Leg Miami, Inc. its directors, employees, and agents, instructors, including volunteers, rescue and support personnel, from any and all liabilities, obligations, damages, claims, causes of action, judgments, costs and charges which I may have or which may be incurred by me for any reason of any occurrence during my travel to and from the event, or during my participation therein, whether resulting from any acts or omissions of any persons, from the operation or condition of facilities or premises, or from acts of God or nature. I hereby agree to comply with all rules and regulations, give my permission for the free use of my name and picture in any media account of the Shake-A-Leg Miami water sports program or any future public relations or fundraising activity. I also agree to assume liability for all and any damages to Shake-A-Leg Miami property that is under my control while participating in any Shake-A-Leg Activity. I hereby attest that the above information is true to the best of my knowledge.

Consent for Photography

I consent to allow the staff of Shake-A-Leg Miami, Inc. to take/use still photographs, digital photographs, motion pictures, television transmission, and/or videotaped recordings (hereinafter “Recordings”) of me or my family for educational, research, documentary, and public relations purposes. Any photos/videos may reveal my and/or my family’s identity without any compensation paid to me, my family, or to others. All photos and videos may be used by Shake-A-Leg Miami for educational and/or promotional purposes and will remain the property of Shake-A-Leg Miami, Inc, I and/or my family hereby waive any and all present and future claims I or my family may have against Shake-A-Leg Miami, Inc., their staff, service providers, employees, agents, affiliates, and Board members to the use of any photos/recordings taken of me, or my family.

Please Check Box to Acknowledge the Waiver and Consent of Photography Terms and Conditions Stated Above:*

I acknowledge

Please Check Box to Acknowledge the Terms and Conditions Stated:*

In the event of an emergency, I grant permissions for my child to be treated at a local hospital.

Confidentiality

Please Check Box to Acknowledge the Terms and Conditions Stated:*

Most importantly, it is your right as the participant to have all your personal records kept confidential. Any information given by you or your family will be treated with respect and not disclosed to anyone who is not authorized to receive such information.

Please sign to acknowledge that all the information provided above is accurate:*

MARINE AND HOSPITALITY VOCATIONAL PROGRAM

Rates Apply

NO REFUNDS!

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