Delta GEMS Registration Form
Participant Info
Youth Name
*
Participant First Name
Participant Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
What grade level is participant?
Freshman
Sophomore
Junior
Senior
School Name
Phone Number
Email Address
*
Participant's email address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
List any clubs or organization in which youth is a member. List any hobbies or interest the youth has.
Program Topic Suggestion/Interests
*
Parent/Guardian Information
Name
*
Parent/Guardian First Name
Parent/Guardian Last Name
Phone Number
*
Parent/Guardian cell phone number.
Preferred method of contact
Relationship
*
Parent/Guardian Email
*
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
If a chaperone or driver is needed, I'll do that.
I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.
The repeated offense of the youth may result in suspension or expulsion.
Parent/Guardian registered in this form has legal custody over the child.
I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult on board.
For medical emergencies, I allow the medical team of this organization to take care of my child.
I release this organization from any and all liability from accident or injury to the child during the organization related events.
Parent/Guardian Signature
*
Date Signed
*
-
Month
-
Day
Year
Today's Date
Submit
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