2nd Annual HBCU College Tour- Breaking Barriers- Building Futures

Y-KNOT Inc. 6178 Oxon Hill Road, Suite 303, Oxon Hill, MD 20745
Student's Name:
DOB
Gender
Address

Address

Street Address Line 2

CityState

Zip
Telephone
Email
example@example.com
Cell#
High School
Classification

FreshmanSophomoreJuniorSenior
GPA
T-Shirt Size
Medical Information: A COPY OF CURRENT INSURANCE CARD MUST BE ATTACHED.
Name of Insurance Carrier
Telephone Number
Policy #
Name of Policy Holder
Co Payment Amount
Insurance Card Upload

Cancelof
LIST ANY ALLERGIES OR MEDICAL CONDITIONS
Emergency Contact Information:
Emergency Contact Name: (must be able to make decisions on behalf of the child)
Relationship

Parent / GuardianAunt / UncleSiblingOther
Daytime Telephone
Evening Telephone
Cell Telephone
Email
example@example.com
Additional Contact Person: (must be able to make decsions on behalf of the participant)
Name
Relationship

Parent / GuardianAunt / UncleSiblingOther
Evening Telephone
Evening Telephone
Cell Telephone
Email
example@example.com

Please initial the authorization statements below.
I authorize the staff to seek emergency medical attention for my child if she/he needs emergency medical treatment. I understand that the team will make every effort to contact me or the emergency contact person upon needing treatment. I understand that the Y-KNOT Inc. staff will not be responsible for any medical expenses incurred due to the lack of emergency medical treatment.
I agree to have my child follow all program guidelines and understand that any violation on the child's part may result in being sent home immediately at the parents' expense.
I give my informed consent and permission for my child to participate in the Y-KNOT Inc. HBCU College Tour and all related activities.
I release Y KNOT Inc. of all liability of injury, death, or damage to me, my child, estate, or assigns that may result form participation in the program, including but not limited to transportation, and hold harmless any program staff or other representatives, both collectively and individually, of any injury, physical or emotional, other then where gross negligence has been determined.
I agree for Y-KNOT Inc. to use photographic images of my child taken while participating in the program. These images may be used in promotional and other related marketing materials.
I understand that my child may be absent from school from March 25, 2024, to March 30, and will be responsible for making up all school assignments as described by the school.
By signing below, I attest to the trustfulness of all information in this application and agree to all the above terms and conditions.
Signature

Clear
Date

MonthDayYear
Date
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