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

Other
Student ID Number
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Are you a U.S. citizen?
If no, are you authorized to work/study in the U.S.?
Do you have a high school diploma or GED?

Other
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.Format: (000) 000-0000.
Alternate Phone (Contact 1)
Please enter a valid phone number.Format: (000) 000-0000.
Second Emergency Contact Name

First NameLast Name
Relationship to Applicant (Contact 2)
Emergency Contact Phone (Contact 2)
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone (Contact 2)
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any medical conditions or allergies we should be aware of?
If yes, please explain your medical conditions or allergies.
Have you ever been convicted of a felony?
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
Date of Signature

MonthDayYear
Date
Admissions Representative Signature
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
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.Format: (000) 000-0000.
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.
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)
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
Date (Parent/Guardian)

MonthDayYear
Date
Should be Empty:

Walker Academy Registration Form

Emergency Information

Enrollment Agreement

Statement of Understanding

Photo & Media Release Form