Detailed Registration Form

Student Information

Student Name*

First NameLast Name

Student Phone Number

Please enter a valid phone number.

Birth Date*

MonthDayYear

Grade*

Gender

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

E-mail*

example@example.com

Emergency Information

#1 Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

#2 Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

# 3 Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler, epi-pen or any other emergency/urgent care treatments or devices? If yes, please explain any instructions.

Approved contacts allowed to pick up above child. Type: Name, Phone, and Relation to minor, if listed as emergency contact already just list name below to approve them for pickup.*

Programs I would like my child to participate in:*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Reality Check, Inc during the next 12 months. In exchange for the acceptance of said child’s candidacy by Reality Check Inc ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Reality Check Inc 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 programs, activities and events. In case of injury to said child, I hereby waive all claims against Reality Check Inc including all staff 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 named child, 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 child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician 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 the Reality Check Inc and its affiliates including Directors, Volunteers, Staff, 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.

Release of Liability

This agreement releases Reality Check, Inc and those affiliated or associated with Reality Check, Inc from all liability relating to injuries that may occur during travel, lodging, food preparation, recreation activities, swimming, kayaking, outdoor activities, and other events organized by Reality Check, Inc or it’s affiliates. By signing this agreement, I agree to hold Reality Check, Inc and those affiliated or associated with said entities entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence. I also release the above organizations, individuals, and entities from any liability from my heirs, family members, or other entities that I the undersigned am associated with.

I also acknowledge the risks involved in participating in Reality Check, Inc. Youth Retreats, recreation center, and programs at Reality Check, Inc. Recreation Center, other host sites- activities, community outreach events, youth/children ministry events and activities including outdoor recreation, after school programs, tutoring, homework help, computer lab, and any and all other voluntary functions. These include but are not limited to injuries from slips and falls, equipment failure, sport injuries, and injuries during travel to and from the event or activity locations. I swear that I/My child am participating voluntarily and that all risks have been made clear to me. Additionally, I/my child do not have any conditions that will increase my likelihood of experiencing injuries while engaging in this activity.

By signing below I forfeit all right to bring a suit against the above mentioned entities, individuals affiliated with entities, board of directors of Reality Check, Inc. and staff/leaders for any reason. In return, I will receive participation as a volunteer in the above mentioned activities that I voluntarily choose to participate in. I will also make every effort to obey safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.

Property Use Agreement

Additionally I agree to treat all properties that I/my child will be using during the aforementioned activities with respect and realize that these properties belong to others and should be treated with care and any and all forms of vandalism, property damage, neglect, or other activities will be avoided.

Photo and video for advertisements, social media and other promotional materials.

I understand that videography as well as photography will be used during some of our events and that your child may videoed or photographed. These images/videos/photos could be included in promotional materials including posting on our social media platforms and website.

I the Legal Guardian fully understand and agree to the above terms relating to my child. I the undersigned, give permission for my child to take part in any events of Reality Check, Inc.

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.

Release of Liability

I the parent or legal guardian of the participant do hereby release Reality Check, Inc , its staff, sponsors, board of directors, volunteers, and members from any and all liability resulting from any physical injury, property damage, or other injury or damage that occurs in connection with the above activities and events. I realize that there are known inherent risks associated with all sport activities and release Reality Check, Inc and its staff, sponsors, board of directors, volunteers and members from all liability and full assume these risks by voluntarily participating or allowing my child to participate in these activities. I also realize that I as the legal guardian will be held responsible for any damage caused to other’s property by my child participating in activities and events with the organization.

Signature of Parent/Legal Guardian*