Unity Club Membership Registration

Unity Club Membership Registration
Student Information
Student Name*
Student E-mail
example@example.com
Grade*
Age
Preferred way to contact

Parent EmailStudent EmailBand AppParent Phone Call
Any medical Conditions, allergies, food allergies, etc. we should be aware of?
Unity Club Membership Registration
Parent/Guardian Information
Parent/Guardian Name 1
Parent/Guardian E-mail 1
example@example.com
Parent/Guardian Phone Number 1
Parent/Guardian Name 2
Parent/Guardian E-mail 2
example@example.com
Parent/Guardian Phone Number 2
Emergency Contacts
Emergency Contact #1 Name
Emergency Contact #1 Phone Number
Emergency Contact #2 Name
Emergency Contact #2 Phone Number
Unity Club Membership Registration
Waivers & Release:
I hereby grant permission for my child to participate in the Unity Club. I understand that activities involve active games, outdoor activities, occasional off-site field trips, etc. I understand that my child's participation in these activities, as well as those program-related activities not listed, may expose them to known danger as well as unanticipated risks. Acknowledging that such risks exist I hear by wave, release, absolve, indemnify, and agree to hold harmless Working Against Violence for Everyone, respective directors, officers, agents, volunteers, and employees from any and all claims of liability for personal injury or property damage my child may suffer while participating.
Date

MonthDayYear
Date
Legal Guardian Signature

Clear
Photo/Video Release
I grant Working Against Violence for Everyone permission to use photographic images and/or video recorded during my child's participation in Unity Club and/or related programs and activities for promotion, publicity, and/or commercial purposes (website, email, print, etcI understand that Working Against Violence for Everyone may associate my child's first name with the aforementioned material but will not associate my child's last name without contacting me first. (do not sign if you do not agree)
Student Signature

Clear
Legal Guardian Signature

Clear
Date

MonthDayYear
Date
Release from Unity Club
Select only one.

I give WAVE staff and volunteers permission to release my child without parental supervision after Unity Club. Selecting allows your child to leave without being released directly to a named guardian.My child can only be released to the named adults. Listed below
1 Adult Name
Name of Adult my child can be released to
1 Adult Phone
Phone number of adult
2 Adult Name
Name of Adult my child can be released to
2 Adult Phone
Phone number of adult
Date

MonthDayYear
Date
Legal Guardian Signature

Clear
Should be Empty:

Unity Club Membership Registration

Student Information

Unity Club Membership Registration

Parent/Guardian Information

Emergency Contacts

Unity Club Membership Registration

Waivers & Release:

Photo/Video Release

Release from Unity Club