COMMUNITY FOR NEW DIRECTION PARTICIPANT REGISTRATION FORM

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1 COMMUNITY FOR NEW DIRECTION PARTICIPANT REGISTRATION FORM Child s Name (Last) (First) (Middle Init.) Address Apt. # Zip Code Home Telephone Message Telephone Birth Age *Gender: Male Female *Race (please check one): African American Somalian White School: Asian Bi-racial Hispanic Grade Allergies (please list): Medications (please list): Parent/Guardian: Emergency contact: Address: (Signature) (Name) (Relationship) (Relationship) Contact Number: *** I understand that my child s participation in the Community for New Direction program is voluntary. *** Parent Signature Staff Signature The Community for New Direction does not discriminate based on race, creed, color, or gender. It is necessary to obtain this information solely for the purpose of tracking community needs. Providing this information will ensure that the proper services continue to be available in the future. For Office Use Only East Office: ( ) West Office: ( ) S.E.E. Vision Conf: A B College Tour: Summer Day Camp After-School 32 week Tutoring In-school mentorship After school Mentorship In school Y.A.P week (circle one) Empower/ on point F.O.C.U.S of Registration Prior Involvement: Yes No

2 2012 Academic College Tour Permission Slip has my permission to attend the 2012 Academic College tour to Vanderbilt University, Tennessee State University, Fisk University, Tuskegee University, Alabama State University, Morehouse University, Spellman College and Clark- Atlanta University with the staff and representatives of the Community for New Direction program. I also understand this is a voluntary activity and is sponsored for selected youth involved in the program. I will not hold Community for New Direction, the members of the Board of Trustees, or its staff and collaborating agencies responsible for any accident or injuries that may occur. Parent Signature Staff Signature

3 2012 Academic College Tour Medical Emergency Authorization I, give the staff of the Community for New Direction permission to seek medical attention for my child, in case of an accident or medical emergency, including if deemed necessary hospitalization at a licensed hospital facility. I also require that a designated staff person contact me to inform me of such an emergency. The number(s) that I can be reached in case of an emergency are: or. I will not hold Community for New Direction, the members of the Board of Trustee, or its staff and collaborating agencies responsible for any accident or injuries that may occur. Parent Signature Community for New Direction Staff Signature

4 Videotaping Authorization, Waiver and Image Release I,, as the parent/guardian of the minor child in consideration of their participation in a Community for New Direction (CND) sponsored activity or program, hereby authorize and consent to the videotaping or recording of my child s image and voice for public display or dissemination. I voluntarily make this authorization and consent fully realizing that in granting my permission I consent to the use of said film, videotape, or photograph in such a manner as CND deems reasonable and necessary. I hereby waive any right, claim or actions that I may have to receive payment, consideration, compensation or royalties for the use of my child s image and voice in all matters videotaped by CND. I also waive any right or claim of privacy that I may have incident to or arising out of the production, creation, making, recording, public display or public dissemination of all said videotape. Furthermore, I, for myself, my heirs, executors, administrators and assigns, forever discharge and hold harmless CND, their agents, and board of directors. ** If the participant is under the age of 18, the following consent of the participant s parent/guardian must be completed ** I represent that I am the parent/guardian of, the above-named individual. For the consideration received above, I hereby consent to the foregoing image release on his/her behalf. Signature of parent/guardian Feb. 9, 12 Printed name of parent/guardian

5 Master Permission Slip I give my child permission to attend all group scheduled and agency approved field trips. I understand that a flyer will be sent home at least two days prior to all out-of-agency and community trips. The flyer will state the place of the trip as well as the time of departure and the time of return. In an emergency, I grant the Community for New Direction staff or their authorized representative permission to seek medical attention for my child. I will not hold the agency, its board, or its staff responsible for any accidents or injuries that may occur. Child s Name Signature (Parent/Guardian) Signature (Group Worker/Staff)

6 Behavioral Contract I and my child agree to the zero tolerance policy of the Community for New Direction 2012 College Tour. I understand that if my child in any way fights with another child he/she will be sent home for the remainder of the tour at my expense. I fully understand that my registration fee will be forfeited. Child s Name Signature (Parent/Guardian) Signature (Group Worker/Staff)

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