Project Pathfinder Registration Form

Project Pathfinder Registration

100 Black Men of Kansas City
Student Information
Students Preferred Name

First NameLast Name
Birth Date

MonthDayYear
School
Grade
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Medical Information (check all boxes that apply and upload any additional relevant detail in the 'file upload' section below). Share any regular medications taken or other instructions to assist members of the 100 when your child is in their care. Note: all medical information is kept private and only used to provide assistance if necessary.
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
What sports or other extracurricular activities does your child participate in? We'd like to support them. You may list below, upload or make a printed version available.
File Upload

Cancelof
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by the 100 Black Men of Kansas City related to Project Pathfinder. In exchange for the acceptance of said child’s candidacy by the 100 Black Men of Kansas City, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the 100 Black Men of Kansas City 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 mentoring sessions.

In case of injury to said child, I hereby waive all claims against the 100 Black Men of Kansas City including all affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the events.

I also authorize the 100 Black Men of Kansas City to use print and/or social media images of my student where relevant and connected with programming.
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

MonthDayYear
Date
Signature
Should be Empty:

Project Pathfinder Registration

Student Information