Walker Academy Registration Form

Walker Academy Registration Form

Building Faith. Developing Leaders. Empowering Youth.Walker Academy Youth Ministry provides a safe, structured, and faith-based environment where youth are supported academically, spiritually, and personally. Through mentorship, education, and community engagement, we help young people discover their purpose and grow into confident leaders.
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Are you a U.S. citizen?*

YesNo
If no, are you authorized to work/study in the U.S.?

YesNo
Do you have a high school diploma or GED?*

YesNoOther
School Name
Graduation Year
Grade Level
Emergency Information

Please provide emergency contact details.
First Emergency Contact Name*

First NameLast Name
Relationship to Applicant (Contact 1)*
Emergency Contact Phone (Contact 1)*
Please enter a valid phone number.
Alternate Phone (Contact 1)
Please enter a valid phone number.
Second Emergency Contact Name

First NameLast Name
Relationship to Applicant (Contact 2)
Emergency Contact Phone (Contact 2)
Please enter a valid phone number.
Alternate Phone (Contact 2)
Please enter a valid phone number.
Do you have any medical conditions or allergies we should be aware of?*

YesNo
If yes, please explain your medical conditions or allergies.
Have you ever been convicted of a felony?*

YesNo
If yes, please explain your felony conviction.
Enrollment Agreement

Please read and sign below to acknowledge agreement.
I, the undersigned, agree to abide by all rules, policies, and procedures set forth by Walker Academy. I understand the nature of the program I am enrolling in and am committed to fulfilling all attendance, participation, and payment obligations.
Student Signature*

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Date of Signature*

MonthDayYear
Date
Admissions Representative Signature

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Date (Admissions Representative)

MonthDayYear
Date
Statement of Understanding

Please read and sign below.
I certify that all information provided is true and complete. I understand that misrepresentation may result in denial of admission or dismissal.
Applicant Signature*

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Date (Applicant)*

MonthDayYear
Date
Photo & Media Release Form

Please indicate your consent for use of photos and media.
Student Name*

First NameLast Name
Program Enrolled
Date of Birth (Media Release)*

MonthDayYear
Date
Phone Number (Media Release)
Please enter a valid phone number.
Email Address (Media Release)
example@example.com
Media Release Permission*

YES – I give permission for Walker Academy, its staff, representatives, and affiliates to photograph, videotape, and/or record my image, likeness, voice, or work product. I authorize the use of these materials for any lawful purpose, including marketing, advertising, educational content, and promotional materials. I understand that these materials may be used in print or online, and I waive any rights to compensation or approval of the final products.NO – I do not give permission for my image, likeness, or voice to be recorded or used in any media by Walker Academy.
I understand that: • My name may be used in association with photos or media unless I request otherwise in writing. • These materials will become the property of Walker Academy. • I may revoke this consent at any time in writing by contacting Walker Academy’s administration.
Student Signature (Media Release)*

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Date (Media Release)*

MonthDayYear
Date
If you are under 18 years old, a parent or legal guardian must complete the section below.
Parent/Guardian Name

First NameLast Name
Relationship to Student
Parent/Guardian Signature

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Date (Parent/Guardian)

MonthDayYear
Date
Should be Empty:

Walker Academy Registration Form

Emergency Information

Enrollment Agreement

Statement of Understanding

Photo & Media Release Form