ISMD Member Application

Member Name*

First NameLast Name

Date of Birth*

Date

Phone Name*

School Name*

Grade*

Age*

County*

OrangeSeminoleOsceola

Gender:*

MaleFemaleOther

Ethnicity:*

Race:*

WhiteBlack/African AmericanNative American

Primary Language:*

EnglishSpanishOther

Parent Name*

Parent First NameParent Last Name

Phone Number *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent Email Address*

Relationship to Member*

Parent Annual Income:*

$10,000-$30,000$30,000-$50,000$50,000-$70,000$70,000-$100,000

Marital Status:*

Single ParentMarriedDivorcedWidowed

Parent Highest Level of Education:*

Emergency Contact 1*

Phone Number*

Emergency Contact 2

Phone Number

Do you have any food allergies? If so, please share in detail any concerns

Do you have any medical conditions? If so, please share in detail any concerns

Member Name*

First NameLast Name

Date of Birth*

Date

I(We), Parent First, Last Name hereby grant,

permission to I See My Destiny Incorporated, for the above named to be video/audio taped and/or featured in promotional publications, informational initiatives, training/educational initiatives and/or presentations of the organization. These materials may include but are not limited to publications and electronic communications produced by I See My Destiny Inc. and/or any of its funders, partners, affiliates or supporting organizations. This includes the use of photographs, voice, audiovisuals and/or public/promotional appearances. The purposes of the publications, informational initiatives, training/educational initiatives, and presentations will be for the promotion of the organization and its services, for training/educational purposes and for fundraising initiatives. I (We) hereby agree to the reproduction and use of my (our) likeness and voice, which may be edited, altered, modified, and revised, for any of the purposes set forth above in all media anywhere in the world at any time without limitation. I (We) hereby grant to I See My Destiny Inc, the right to use my (our) performance and/or voice and/or likeness for any of the purposes set forth above in all media anywhere in the world at any time without limitation. I (We) release and discharge all designers, printers, publishers, producers, photographers, videographers, researchers, trainers, production teams, I See My Destiny Inc, its agents, and employees from all liability, claims or demands in law or in equity arising from the use of such features, photographs, voice, audio/visual materials and/or public/promotional appearances. I (We) authorize that a photocopy of this authorization may be considered as valid as the original. I understand that my agreement to participate in any of these activities is voluntary. I also understand that I may revoke this authorization at any time, providing I notify the program in writing to this effect. Revocation has no effect on action previously taken.

Signature of Member*

Signature of Parent/Guardian*

Date*

Date

Program Application

AUTHORIZATION TO BE FEATURED IN PROMOTIONAL PUBLICATIONS, INFORMATIONAL/TRAINING/EDUCATIONAL INITIATIVES AND/OR PRESENTATIONS