Registration Form

Registration Form

English

Student Information
Full Name*

First NameMiddle NameLast Name
Gender*
Birth Date*

MonthDayYear
Age*
Current School*
Current Grade Level*
Phone Number*
Email*
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Ethnicity*
Check one option that best applies
Do you have a physical or mental disability you’d like to disclose?*
If yes, please provide more information:
Do you have any allergies?*
If yes, please provide more information:

Parent/Guardian Information
Parent/Guardian Name ( 1 )*

First NameLast Name
Relationship to Student*
Primary Language*
Phone Number*
Email*
Parent/Guardian Name ( 2 )

First NameLast Name
Relationship to Student
Primary Language
Phone Number
Email
Estimate Your Family Annual Income*

Emergency Contact Information
Emergency Contact (Different from Parent/Guardian above)*

First NameLast Name
Relationship to Student*
Address Of Person To Contact In Case Of Emergency*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Of Person To Contact In Case Of Emergency*
Please enter a valid phone number.
Email Of Person To Contact In Case Of Emergency

Additional Information
Is there any additional information you would like to share?

Waiver & Release
IMPORTANT INFORMATION: Tailoring Youth to Succeed (TYS) is committed to conducting its recreation programs and activities safely and holds the safety of participants in high regard. TYS continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. However, participants and parents/guardians of minors registering for this program/activity must recognize an inherent risk of injury when participating in recreational activities/programs. You are solely responsible for determining if you or your minor child/ward are physically fit and/or adequately skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled in any way, or has recently suffered an illness, injury, or impairment, to consult a physician before undertaking any physical activity. WARNING OF RISK Recreational activities are intended to challenge and engage each participant's physical, mental, and emotional resources. Despite careful and proper preparation, instruction, medical advice, conditioning, and equipment, there is still a risk of serious injury when participating in any recreational activity. All hazards and dangers cannot be foreseen. Depending on the particular activity, specific threats, dangers, and injuries may exist due to inclement weather, slips and falls, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defects, inadequate or defective equipment, inadequate supervision, instruction or officiating, and other risks inherent to the particular activity. In this regard, TYS can't guarantee absolute safety.

WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK Please read this form carefully and be aware that in signing up and participating in this program/activity, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with this program/activity(including transportation services and vehicle operations, when provided).

I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, and I voluntarily agree to assume the entire risk of any and all injuries, damages, or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) due to participating in this program/activity against TYS, including its officials, agents, volunteers, and employees.

PHOTO POLICY Registrants and participants of programs and special events permit TYS to take photos and videos of themselves and their children for publication in the seasonal program brochure, website, and additional uses as TYS deems necessary unless the registrant or participant expressly files with TYS a written objection as to photos or videos of themselves and/or their children.

I have read and fully understand the above important information, warning of risk, assumption of risk, waiver, and release of all claims. If registering online or via fax, my online or facsimile signature shall substitute for and have the same legal effect as an original form signature.
Today's Date*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature (If under 18 years old)*

Powered by Jotform SignClear
Please verify that you are human*
Should be Empty: