MORE THAN a Boxing Program

______

“MORE THAN a boxing program”

A program of Life Community Development Corporation

REGISTRATION AND PAYMENT FORM

______

NAME OF THE PARTICIPANT

______

DATE OF BIRTH

______

ANY ALLERGIES OR MEDICATIONS TAKEN

______

PARENT/GUARDIAN NAME

______

ADDRESS

______

PLACE OF EMPLOYMENT

______

HOME PHONE WORK PHONE CELL PHONE

______

EMERGENCY CONTACT RELATIONSHIP PHONE NUMBER

______

PAYMENT AMOUNTMODE OF PAYMENTCHECK NUMBER

______

CREDIT CARD TYPENUMBER and EXP. DATE NAME ON CARD

______

PARENT/GUARDIAN SIGNATURE Date

______

“MORE THAN a boxing program”

A program of Life Community Development Corporation

NOTE: ALL members MUST have this permission form signed by parent/guardian.

PERMISSION AND RELEASE FORM

I, ______, parent/guardian of ______

do hereby grant Conquerors access to my child’s grades, attendance report, and information regarding low income verification from Rochester Public Schools, Olmsted County Social Services/Support for LIFE COACH and program purposes. I also consent that my child may be transported from school and home by a CONQUERORS volunteer or escorted to the nearest bus stop if I fail to pick-up my child by the time CONQUERORS program concludes and do hereby personally, and on behalf of my child, release Conquerors from any claim for personal injuries which might be sustained by my child while participating in activities or returning to His/her home.

______

Parent/Guardian Signature Date

______

Life CoachDate

Child’s Name / Date form completed/updated
Date of Birth / Home Address / City, State, Zip / Home Telephone:
Is your child on Free and Reduced Lunch: / Child’s Ethnicity: / Name of child’s school/Grade
Parent/Guardian Name / Relationship to Child / Parent/Guardian Name / Relationship to Child
Home Address / Employer/School / Home Address / Employer/School
City, State, Zip Home / Address & City: / City, State, Zip / Address & City:
Home Telephone:
Cell Phone: / Work/School Phone: / Home Telephone:
Cell Phone: / Work/School Phone:
Emergency Contacts: List the names of others local persons who you want to be contacted in the event of an emergency or illness if the parent/guardian cannot be reached. Persons listed should be able to assist in locating the parent/guardian and at least one person listed must be able to take responsibility for the child in cases where the parent/guardian cannot be located.
Name / Name
City/State / City/State
Telephone Number / Relationship to Child / Telephone Number / Relationship to Child
Referring Organization (if applicable): / Name of organization / Contact Name / Address
Phone / Email

______

“MORE THAN a boxing program”

A program of Life Community Development Corporation

PERMISSION AND RELEASE FORM FOR MEDIA USE

I, ______, parent/guardian of ______

do hereby grant Conquerors (LIFE CDC), the Rochester Family YMCA, and/or Bear Creek Church to utilize any pictures, video’s, etc. for brochures, websites, and/or all other media and marketing purposes. I understand that any of such uses will not be used to negatively expose my child, family, etc.

______

Parent/Guardian Signature Date

______

Life CoachDate