Boys & Girls Confidence Academy Enrollment

Child's Information

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about the Boys & Girls Confidence Academy?*

Parent/Guardian Information

Name*

First NameLast Name

Home Number*

Area CodePhone Number

Cell Number*

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number*

Area CodePhone Number

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the child prescribed an inhaler? If yes, please explain any instructions.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by In This For Life Virtual Volunteers, Inc. during their participation in the Boys or Girls Confidence Academy. In exchange for the acceptance of said child’s candidacy by Boys or Girls Confidence Academy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless In This For Life Virtual Volunteers, Inc. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected Boys or Girls Confidence Academy sessions.

In case of injury to said child, I hereby waive all claims against In This For Life Virtual Volunteers, Inc.. including all staff and affiliates, all participants, volunteers, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct events or activities.

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the In This For Life Virtual Volunteers, Inc.. and its affiliates including Directors, Staff, and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence at in person events or activities.

Confirmation

BY SUBMITTING THIS FORM, YOU ARE ACKNOWLEDGING AND SIGNING BELOW THAT YOU ARE DELIVERING AN ELECTRONIC SIGNATURE WITH THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.