Victorville Workshop #2 Registration Form
Please fill out the required information to complete registration.
Student Information
Participant's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
School
*
Grade
*
Parent or Guardian Name
*
First Name
Last Name
City
*
Parent/Guardian Information
Parent or Guardian Name
*
Relationship to Student
*
Parent or Guardian Email
*
example@example.com
Parent or Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Does the student have any allergies?
*
Any special accommodations needed?
*
Getting to Know Your Daughter
What interests your daughter most?
*
Leadership
Building Confidence
Making Friends
Community Service
Public Speaking
College Preparation
Career Exploration
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
No
Authorized Pick-Up
Authorized Person's Name
*
First Name
Last Name
Relationship to Participant
*
Phone Number
*
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
IMARA Website
Flyer
Community Partner
Other
Has your daughter attended any other IMARA Events?
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Register
Register
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