B-RELYT Programs

Black Math Collective Virtual Saturday School 2024 Form

Starts Saturday, September 21, 2024
Section I: Student Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student's Email*
example@domain.com
Name of school you are attending*
Grade Level Fall 2024*
Extra-curricular activities you are currently participating in:
What are your career interests?
What would you like to learn more about?

MathScienceTechnologyEngineeringOther
Section II: Parent/Guardian Information

Parent/Guardian
Full Name*

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Parent/Guardian Email*
example@domain.com
My address is the same as student's address
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian 2
Full Name

First NameLast Name
Cell Number
Please enter a valid phone number.
Other Number
Please enter a valid phone number.
Parent/Guardian 2 Email
example@domain.com
My address is the same as student's address
Section III: Emergency Contact Information
Full Name*

First NameLast Name
Relationship*
Emergency Contact Email*
Cell Phone*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Section V: Parental Consent for Photography and Participation in Evaluation Studies

Please indicate if you give permission for your child to participate in the following activities:
Photography*

Yes, I give permission for my child to be photographed for the Black Math Collective, including photos, slides and video.No,
Media/Photo Release*

I grant permission for my child to be photographed or recorded on video during their participation in the Black Math Collective Saturday School Program. I also authorize the use of their photo or image in any publications or promotional materials related to the BMC Program.I do not give permission for my child to be photographed or videotaped during their involvement in the Black Math Collective Saturday School Program. I also do not authorize the use of their photo or image in any publications or promotional materials related to the BMC Program.
Media Release of Information*

Yes, I give permission for my child to participate in evaluation studies conducted by the Black Math Collective organization. This may include observations of my child during regular program activities, anecdotal notes on their progress toward objectives, and the use of developmental assessments and other evaluation results. I understand that all information will be kept confidential, and my child's full name will not appear in any reports of the results, except for confidential reports required by the state or school district.No, I do not give my permission for my child to participate in evaluation studies for the Black Math Collective organization.
I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote B-RELYT's mission dba Black Math Collective.
Please read the RELEASE AND WAIVER OF LIABILITY FOR ALL AFTER SCHOOL CLASSES AND PROGRAMS.
I have read the RELEASE AND WAIVER OF LIABILITY for all after school classes and programs.*

YesNo
Parent/Guardian: In signing this Acknowledgement of Risk and Waiver of Liability I hereby acknowledge and represent that I am of legal age and have read this document in its entirety, understand it, and sign it voluntarily.*

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Parent/Guardian Name*

First NameLast Name
Students Name*

First NameLast Name
Date*

MonthDayYear
Date
PARENT/GUARDIAN: Participants under the age of 18, or those not legally competent, must sign above and obtain the signature of a parent or legal guardian below. I certify that I am the parent or legal guardian of the participant named above. I confirm that I have read and understood the agreement, and I agree to its terms and conditions. I acknowledge that my dependent and I have accepted the terms of their participation, and I give my consent for their participation as well as any necessary medical treatment. Additionally, I agree to hold harmless, indemnify, and defend the Black Math Collective (BMC) and all BMC staff from any claims, demands, or suits that my dependent may have now or in the future.*

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Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
PARENT/GUARDIAN 2: Participants under the age of 18, or those not legally competent, must sign above and obtain the signature of a parent or legal guardian below. I certify that I am the parent or legal guardian of the participant named above. I confirm that I have read and understood the agreement, and I agree to its terms and conditions. I acknowledge that my dependent and I have accepted the terms of their participation, and I give my consent for their participation as well as any necessary medical treatment. Additionally, I agree to hold harmless, indemnify, and defend the Black Math Collective (BMC) and all BMC staff from any claims, demands, or suits that my dependent may have now or in the future.*

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Parent/Guardian 2 Name

First NameLast Name
Date

MonthDayYear
Date
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Black Math Collective Virtual Saturday School 2024 Form

Section I: Student Information

Section II: Parent/Guardian Information

Section III: Emergency Contact Information

Section V: Parental Consent for Photography and Participation in Evaluation Studies