The RESET Registration & Waiver Form

The RESET Registration & Waiver Form

Please complete all sections to register for The RESET program and review the waiver.
Participant Information
Participant Full Name

First NameMiddle NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender
School or Organization Name
Grade Level
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Full Name

First NameMiddle NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Parent/Guardian Signature
Program Interest & Support Needs
What types of support or program interests are you looking for?

Other
What challenges, goals, or support would you like us to know about?
Medical & Safety
Allergies
Medical conditions
Current medications
Mental health concerns or triggers we should be aware of
Emergency medical authorization
Liability Waiver & Release
Participant Signature
Parent/Guardian Signature (if under 18)
Date

MonthDayYear
Date
Communication Opt-Ins
Communication preferences
I consent to receiving text and emails from Be The Proof Foundation. I understand I can text STOP to opt out.
Should be Empty: