Legacy Prep Academy Student Registration

Student Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age*

Birthdate*

Date

Gender*

MaleFemale

Ethnicity*

African AmericanAsian/Pacific IslanderCaucasianHispanic/Latino

Is your child a "new" or "returning" student to Legacy Prep?

NewReturning

Name of Current School*

Grade Level*

Does Student Have an IEP*

YesNoNot Sure

What Subjects does Student Need Support?

Parent/Guardian Information

Parent Name*

First NameLast Name

Address*

City*

State*

Zip Code*

Cell Number*

Home Number*

E-mail

example@example.com

Primary Language Spoken at Home*

Emergency Contact Information

Emergency Contact's Name

First NameLast Name

Relationship to Student

Phone Number

Alt. Phone Number

Insurance Provider

Policy Holders Name

Medical Policy Number

Doctors Phone Number

Please enter a valid phone number.

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe all food allergies and medical conditions or enter NONE if none exist.*

Type None if no allegries or illnesses exsist

Is the student prescribed an inhaler or other emergency medications? If yes, please explain any instructions. If No, enter 'None'.*

Type 'None' if no medication is prescribed

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep during the selected session. In exchange for the acceptance of said child’s candidacy by Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep. 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 selected camp sessions.

In case of injury to said child, I hereby waive all claims against Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep. including all coaches 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.

Medical Release and Authorization

As Parent and/or Guardian of the above named astudent, 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 the attending physician will make every attempt 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 Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep. 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.

Photo Consent Form

I am the parent/guardian of the student named above as (“My Child”). I hereby grant Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep, and their agents the absolute right and permission to use
photographic portraits, pictures, digital images, or videotapes of My Child, or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any University publication or on Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep websites, without payment or any other consideration.

I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied.

I hereby release, discharge, and agree to indemnify and hold harmless the Emmanuel Baptist Church, Legacy Preparatory Academy Afterschool Program, A.K.A Legacy Prep, and their agents from all claims, demands, and causes of action that My Child or I have or may have by reason of this authorization or use of My Child’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional, or otherwise, that may occur or be produced in the taking of said images or videotapes or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials.
I represent that I am at least eighteen (18) years of age and am fully competent to sign this Release.

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.

Date*

Date

Signature

Legacy Prep 2024-2025 Fall Registration Form

Student Information

School Information

Medical/Health Insurance