SELA Academy Registration Form

Savannah Enrichment & Learning Academy Registration
Participant Information
Participant Name

First NameLast Name
Birth Date

MonthDayYear
AGE*
GRADE*
Current Enrolled School
Shirt Size
Gender

MaleFemale
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Alt. Phone Number
Persons Allowed To Pick Up

I understand that any person that is not listed below will not be able to pick up said participant until verfied by me in written form.
Contact's Name*

First NameLast Name
Relationship
Phone Number*
Contact's Name

First NameLast Name
Relationship
Phone Number
Signature*

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Date*

MonthDayYear
Date
Select Registering Program

Enrichment Learning Summer Camp 2024Direct Learning and Comprehension Program (School Year Service)College Acceptance PrepMath CampReading CampMath and Reading Camp
Does the participants have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Does the participant take any daily medications? If yes, please explain any instructions.*
If the participant takes any daily medications. Will any medication need to be given by Savannah Enrichment Academy Company Staff? If yes, please list the medication/s as well as time and dosage.
I give Savannah Enrichment Academy Company staff and its affiliates permission to administration my child medication as it has been stated above.
Signature

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Date

MonthDayYear
Date
Participant Health Provider Information
Primary Care Provider Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Emergency Information
PLEASE PROVIDE HOSPITAL NAME THAT YOU WOULD LIKE YOUR CHILD/CHILDREN TO BE TRANSPORTED TO IN THE EVENT THAT MEDICAL ASSISTANCE IS NEEDED.*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Savannah Enrichment Academy Company while enrolled. In exchange for the acceptance of said child’s candidacy by Savannah Enrichment Academy Company, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Savannah Enrichment Academy Company. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from and event and or activity.

In case of injury to said child, I hereby waive all claims against Savannah Enrichment Academy Company including all employees and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Signature*

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Date*

MonthDayYear
Date
Medical Release and Authorization

As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Savannah Enrichment Academy Company. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Signature*

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Date*

MonthDayYear
Date
Insurance Information
Do the participant has Health Insurance Coverage*

YES- UPLOAD INSURANCE CARDNo
IF YES; Please Upload Insurance Card Or Bring a Copy to Open House

INSURANCE CARD
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Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
SIGNED PERSON IDENTIFICATION CARD*

IDENTIFICATION CARD
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Date*

MonthDayYear
Date
Signature*

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Savannah Enrichment & Learning Academy Registration

Participant Information

I give Savannah Enrichment Academy Company staff and its affiliates permission to administration my child medication as it has been stated above.

Participant Health Provider Information

Emergency Information

Insurance Information