Building Resilience in African American Families – FAMILY APPLICATION

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Please complete the following on-line application to be considered for enrollment in the Building Resilience in African American Families program. You must provide all information in order that your youth and family may be evaluated for eligibility. To apply for more than one child please complete a separate application for each child.

Parent/Guardian *

First

Last

Relationship to youth *

Parent/Guardian

First

Last

Relationship to youth (copy)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Program Selection *

BRAAF BOYS
BRAAF GIRLS

Name *

First

Last

Birthdate *

Race/Ethnicity *

Grade 2021/22 *

School *

Transportation request

Families Achieving Success will make every effort to provide transportation to as many youth as need it to get to and from BRAAF in the Mid-County region. If you do not need transportation, please allow the families who need that service the opportunity to receive transportation. Transportation will be provided for ALL enrolled youth to and from outings and retreats.

Consent for Participation: I, the parent or guardian of the above named child, hereby register my youth for participation in the Africentric Rites of Passage Program, and fully agree to the rules and regulations of the Families Achieving Success and do hereby release Families Achieving Success and its directors, representatives, employees, and volunteers from any liability. I, the parent or guardian, releases Families Achieving Success from all responsibilities from injuries of any nature incurred while participating in the program activities. I understand that my child will be supervised by a trained staff at all times, and that medical insurance is my responsibility. *

*I have read, understand and agree to the terms of the Consent to Participation.

Photograph Release Agreement: This agreement is made between myself and Families Achieving Success. I, hereby grant permission for Families Achieving Success to use photographs for use in any and all media and methods of transmission and/or distribution now or hereafter known, including but not limited to film, print, video, computer. Worldwide Web, Internet Websites, Email, FTP, computer network, and digital reproduction and distribution for illustrations and promotion, advertising, trade, sales or any other purpose whatsoever. I hereby waive any right to inspect or approve the photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to organization or unknown, including but not limited to any re-use, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur in relation to the finished product. I hereby agree to hold harmless Families Achieving Success from and against any claims and waive any right to royalties or other compensation arising from or related to the use of the photographs. *

*I have read, understand and agree to the terms of the Photograph Release Agreement

Emergency Medical Treatment In the event my child becomes ill or sustains an injury while in the care of or under the supervision of the staff, volunteers or other Families Achieving Success representatives, they are given permission to administer first aid for relief. In case of emergency, permission is given to take my child to the nearest appropriate emergency or clinic facility. Please enter Physician Name: *

First

Last

Physician phone number *

Allergies (if any)

Medications (if any)

Emergency Contact - 1 *

First

Last

Phone *

Emergency Contact - 2 *

First

Last

Phone *

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Application. *

"I Accept"

Type your name as your Electronic Signature *

Where did you hear about us? *