The Opportunity Project Registration

Applicant's Legal Name

First NameLast Name

Nickname

Birthdate

Date

Age

Gender

Race/Ethnicity

Preferred Pronouns

Last 4 of SSN

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Phone of applicant. If applicant is a minor, Parent/Guardian phone number is requested below.Format: (000) 000-0000.

Email

Email of applicant if applicable. If applicant is a minor, Parent/Guardian email is requested below.

Last School Attended.

If school is not in Duval county, please indicate.

Current Grade Level (if in school)

Where are you in the process of completing high school or GED?

How did you hear about this program?

#TheOpportunityProject
This program is Monday through Thursday or Tuesday through Friday from 9am - 3pm, depending on which cohort. Breakfast and lunch are provided. This program is intended for individuals transitioning to adulthood, between the ages of 16 and 21.

Which Cohort are you interested in?

Select your career aspiration.

List any medications prescribed including dosage and frequency.

List any allergies you have.

List any dietary restrictions you have.

Please list any special needs you may have.

Do you allow The Opportunity Project to use your (the minor applicant's) data for impact reporting now and in the future?

Do you wish to receive emails regarding other programs and events from The Performance Academy?

Consent Form & Release of Liability Waiver

I am signing this Consent Form and Release of Liability Waiver for the purpose of authorizing the above named my (or the minor applicant's) participation in the enrichment activities, and provision of meals by staff and volunteers associated with the above program. I acknowledge that this is a voluntary activity for which I freely give permission for participation.

I further give my consent for my (or the minor applicant) to be photographed or videotaped during the activities involved in this learning experience and grant permission to The Performance Academy to use said photos or videos for promotional and/or educational purposes. Said consent is given without any expectation of compensation or reward for any photos taken and/or used in educational and promotional literature.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Name of Applicant or Parent/Guardian Name (if applicant is a minor).

First NameLast Name

Parent/Guardian Phone Number (if applicant is a minor)

Please enter a valid phone number.Format: (000) 000-0000.

Date

Emergency Contact Name

This is the person who should be responsible for taking any incident reports regarding youth or to pick up youth if absolutely necessary.

Emergency Contact Phone

Do you wish to receive emails regarding other programs and events from The Performance Academy?

I am happy to allow The Opportunity Project to use my data for impact reporting now and in the future

Signature of Applicant OR Parent/Guardian (if applicant is a minor).