Clone of WALLACE FOUNDATION COHORT- HELIX AVIATION ACADEMY

Child Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Name of School

Parent/Guardian Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

Physician Name

First NameLast Name

Phone Number

Area CodePhone Number

Medical Concerns or Allergies

Have you participated in the LYFE program before?

Why do you believe you should be selected to participate in the Wallace Foundation Cohort?

Define what leadership means to you.

Are you able to attend our 3-day workshop with LYFE Friday, July 24-Sunday, July 26 from 3-7pm?

Are you available for our HBCU Experience trip to New Orleans, LA July 31- August 2?

Are you available for our HBCU Experience trip August 27- August 30?

Are you able to fully commit to our Summer 2026 experience?

Shirt Size

Signature

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES being conducted by The Wallace Foundation including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I CERTIFY that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I CERTIFY that there are no health-related reasons or problems which preclude my participation in this activity. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (1) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers; (2) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise. I acknowledge that The Wallace Foundation and their directors, officers, volunteers, representatives, and agents are NOT responsible for errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. I acknowledge that this activity may involve a test of a person's physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people, including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants, but are also present for volunteers. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns. The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.*

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT. By submitting below, I am stating that all above information is accurate and true, and I agree to the electronic communication terms within this form.

By completing this registration form, I understand and agree that, if need be, I give the Wallace Foundation Staff approval to discipline my child through verbal correction, time-out sessions, suspension, or ultimately expulsion.

The Wallace Foundation Strong Summer Experience 2026

Our Mission

About LYFE

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

MEDICAL INFORMATION

PERSONAL INFORMATION