PRogram application – G3 Life Applications, Inc.

Student Information

Please enter the information of the student you wish to register for a G3 activity.

Name *

First

Last

Nickname *

What name does the student prefer to be addressed.

Age

Please enter the students age

Date of Birth *

Medical Concerns

Please enter any allergies or special abilities or accommodations the student needs.

Date / Time

Date

Time

Name of School

School lunch provision *

Free
Reduced
Neither

Please enter the school lunch designation for the student.

Student Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please enter the home address of the student

Student Email *

Enter the student email address

Student Phone

What is the preffered method of contact *

Text
Phone
Email

Please indicate your preference for communication.

Additional Children/Students

Please enter any additional children you want to register for activities with G3.

Program Area of interest

Please select all the of the activities and programs which you plan to register your child.

Registration category *

Please select all programs that apply for this application

Other interest and inquiries

If there are any other interests or program inquiries for which you wish to register please specify in the field above.

Parent/Guardian Information

Name *

First

Last

Email *

Phone *

Address (enter if different than student)

Address Line 1

Address Line 2

City

State

Zip Code

Please enter the address of the parent/guardian if it is different than the student's address.

Emergency Contact

Name *

First

Last

Phone *

Relationship *

Alternate Name

First

Last

Alternate Phone

alternate emergency phone

Alternate's Relationship *

Household Information

Student/ Child lives with: *

Mother
Father
Grandparent
Other

Please select all that apply.

Number in household *

Please enter the number of people in your household including yourself

Are you currently a single parent?

Parent / Guardian Consent

Please complete the acknowledgement and consent information in the form below.

Participation consent

I give consent for my child, to Participate in the Youth fitness training programs and/or recreational activities workshops, and field trips provided by G3 Life Applications, Inc.

Child Name *

Please enter the name(s) of the children you wish to give activity consent.

Parent Guardian name: *

Parent/ Guardian Signature *

Clear Signature

Date *

Consent Date

Wavier & Release of Liability Minor

Liability waiver

In consideration of my child being allowed to participate in any way in G3 Life Applications, Inc. fitness training and recreational programs, the undersigned acknowledges that:

1) For myself, spouse, and child, I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the participants, spectators, administrators, or others, and assume full responsibility for my child’s participation; and

2) If I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from the participation and bring such attention of the nearest official immediately; and

3) I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY, RELEASE AND HOLD HARMLESS G3 Life Applications, Inc.; it’s directors, officers, volunteers, employees, other participants, and if applicable sponsoring agencies, sponsors, advertisers, and owners and lessors of premises used to conduct the event, with respect to any and all liabilities incidents, injury, disability, death, or lessor damage to person or property incident to my or my child’s/ward’s involvement or participation in these programs, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law.

I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.

Child(s) Name *

Please enter the name(s) of the children you wish to give for waiver of liability.

Parent/ Guardian Signature for liability waiver *

Clear Signature

waiver signature

Date *

Waiver consent date

Photo/Video Release

Photo/Video agreement

G3 Life Applications, Inc. has my permission to take, use, re-use, publish, and republish photographic portraits, pictures or video of me, or my children, in whole or in part, or composite or distorted in character form, without restriction to alterations/changes, made through any and all media now or hereafter, specifically including but not limited to print media, the internet, promotion, art, advertising, Editorial, trade, or any other purposes.

Parent/ Guardian Signature for photo/video *

Clear Signature

photo and video release signature

Date *

Photo/Video consent date

Areas of Mentoring/Discussion Consent

Mentoring/ Discussion agreement

G3 Life Applications, Inc. is dedicated to youth development and well-being. This includes discussion and education of life experiences that shape and mold our participants. Character development is an integral part G3 Life Applications, Inc. The following areas will/may be addressed at an age-appropriate level: health, wellness, nutrition, tutoring, job training, school readiness, faith and Spirituality, healthy relationships, HIV/AIDS, safety and prevention, self-care, career development, communication as well as other topics that can encourage and enrich healthy choices.

I give consent for my child to be educated and informed on an age-appropriate level regarding the above stated topics.

Parent/ Guardian Signature for photo/video (copy) *

Clear Signature

Mentoring and discussion signature

Date *

Mentor/Discussion consent date

Register Additional Children

Please add any additional children you wish to include for the above activities and release consent.

Student 2 Name

First

Last

Nickname

Enter the preferred name of the student

Age

Date of birth

School

Grade

Allergies or special abilities

Please enter any allergies or special requirements

Student 3 Name *

First

Last

Nickname *

Age

Date of birth

School

Grade

Allergies or special abilities (copy)

Please enter any allergies or special requirements