Registration Form
Please fill out the required information to complete your registration.
Student's Name
*
First Name
Last Name
Age
Grade
School
City
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Phone
Text
Email
Emergency Information
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies
Special Accommodations Needed
Getting to Know Your Daughter
What interests your daughter most? (Check all that apply)
Leadership
College Preparation
Career Exploration
Building Confidence
Making Friends
Community Service
Financial Literacy
Public Speaking
Other
What do you hope your daughter gains from participating in IMARA?
Permissions
Parent Permission: I give permission for my daughter to participate in The IMARA Project Victorville Program
*
Yes
Photo & Media Release: I grant permission for photographs and video taken during IMARA activities to be used for educational, promotional, fundraising, social media, website, and reporting purposes.
*
Yes
No
Will a parent or guardian remain on-site during the workshop?
Yes, I plan to stay during the event.
No, I will be dropping off my child and returning for pick-up.
Authorized Pick-Up
Authorized Person #1 Name
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Medical Treatment: In the event of an emergency, I authorize emergency medical treatment if I cannot be reached.
*
Yes
No
Self-Release for Older Participants
Self-Release Authorization
I authorize my child to leave the event independently without a parent or guardian present.
My child is not authorized to leave independently and must be picked up by an authorized adult.
How did you hear about this event?
School
Friend/Family
Social Media
Community Center
IMARA Website
Flyer
Community Partner
Other
Communication Consent
Communication Consent
I consent to receive emails from The IMARA Project.
I consent to receive phone calls from The IMARA Project.
I consent to receive text messages from The IMARA Project.
Signature
Signature Date
-
Month
-
Day
Year
Date
Register
Should be Empty: