Determined to Rise Academy Registration

Dear Parent/Guardian, thank you for your interest in Ms. JD's Determined to Rise Academy. To register your child, please fill out this form.

Name of Parent/Guardian

Determined to Rise Event

Email

Parent/ Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/ Guardian Phone Number

Name of Child

Child's Age

Child's School Name

Child's Grade

Please list any dietary restrictions your child has.

Please list the name and phone number of an emergency contact other than yourself.

How did you hear about the Determined to Rise Academy?

Other

PERMISSION FOR PARTICIPATION: I, the undersigned, certify that I am the parent or legal guardian of the above-mentioned child. I hereby authorize my minor child named above to attend and participate in Ms. JD's Determined to Rise Academy (the "Event"). I understand that my minor child must obey all established rules and follow the instructions of the person in charge of the Event. By signing this parental consent, I expressly assume all risks to my child’s participation in the Event, whether such risks are known or unknown to me at this time.In recognition of these risks and realities, and in consideration of my child being offered the opportunity to participate in and benefit from the Event, I agree on behalf of myself and my child to release, waive, and disclaim any and all liabilities of or claims against, Ms. JD, its officers, board members, agents, and/or employees who may supervise my child while participating in the Event including, but not limited to any or all liabilities or claims for personal injury, property damage, court costs, attorneys’ fees, and interest, however, caused or accrued, as a result of my child participating in the Event. I hereby give Ms. JD the right and permission to photograph, digitally record, or videotape my above-named child while s/he is attending and participating in the Event. I further agree that any or all of the material recorded may be used in any form and that such use shall be without payment of fees, royalties, special credit, or other compensation.I recognize that there may be occasions where the minor child named above, may be in need of first aid or emergency medical or dental treatment as a result of an accident, illness, or other health condition or injury. Therefore, I authorize any Ms. JD board member, employee, or volunteer, in whose care the minor child has been entrusted, to consent to any X-ray, examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the provisions of the Medical Practice Act by the medical staff of a licensed hospital. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment. As a parent or legal guardian of my minor child (Participant named above), I am responsible for the health care decisions of my minor child and am authorized to consent to the services to be rendered.I represent that my consent to and agreement to pay for dental, medical, and/or hospital care or treatment to be rendered to my minor child is legally sufficient and that no consent from any other person is required.I have read, understood, and agreed to the information above. (PLEASE TYPE YOUR NAME BELOW.)