Menifee Union School District

Student Name *

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Last

Parent Name *

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Last

Parent Name

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Last

Email *

Phone number *

Address

Address Line 1

Address Line 2

City

State

Zip Code

What school do you attend? *

What grade are you in *

Enroll me for Brotherhood/Sisterhood at which school site? *

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

Phone number

Allergies *

Medications *

Emergency Contact *

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Last

Phone Number *

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