College Prep | Indianapolis Youth Development

First Name*

M.I.

Last Name*

Gender*

Date of Birth*

STN:

8 digit school ID

Ethnicity*

(If other, please specify)

Email*

Cell Phone*

Address 1*

Street address, P.O. box, Company name, c/o

Address 2

Apartment, suite, unit, building, floor, etc.

City*

State*

Zip*

Student lives with:*

Specify Other

Guardian (1)

Guardian (1) First Name*

Guardian (1) Last Name*

Guardian (1) Maiden Name (if applicable)*

Guardian (1) Type*

Guardian (1) Email*

Is address same as student?

Yes

check this box if address is the same as the students

Address (1)*

City (1)*

State (1)*

Zip (1)*

Home Phone (1)

Work Phone (1)

Cell Phone (1)

Guardian (2)

Guardian (2) First Name

Guardian (2) Last Name

Guardian (2) Maiden Name (if applicable)

Guardian (2) Type

Guardian (2) Email

Is address same as student

Yes

check this box if address is the same as the students

Address (2)

City (2)

State (2)

Zip (2)

Home Phone (2)

Work Phone (2)

Cell Phone (2)

Parent/Guardian Participant First Name #1

Parent/Guardian Participant Last Name #1

Parent/Guardian Participant Type #1:

Parent/Guardian Participant Type #2:

Parent/Guardian Participant First Name #2

Parent/Guardian Participant Last Name #2

# of Participants

I hereby give permission for my child, named above, to attend and participate in Center for Leadership Development’s (CLD) programs, activities, and initiatives. For the purposes of marketing CLD programs, I hereby give permission for my child to be photographed and/or video graphed. Any data collected by CLD from various vehicles is private and confidential. Data may include, but is not limited to: ISTEP scores, CTBS, and standardized testing covered by FERPA, as well as grades, school attendance records, behavioral records and log sheets. It is also understood that data collected will protect my child’s identity, although CLD, its assigns, or successors may use the data to determine current trends. The data collected is the sole property of CLD.

I am the natural parent or legal guardian having custody of said child. In consideration of my child participating in CLD, I hereby voluntarily release and agree to hold harmless and indemnify the Center for Leadership Development (CLD), each of its directors, officers, employees, volunteers, and its partner organizations from and against any and all liability, claims, demands, actions, damages, expenses and costs, including attorney’s fees, losses and judgments of whatsoever kind and nature which may result from or arise out of my child’s participation whether or not resulting in whole or in part from negligence, acts or omissions of CLD or its directors, officers, employees, volunteers, or partner organizations, or of said child.

In the event that I cannot be reached in an emergency, I hereby give permission to the CLD staff/volunteer(s) to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician or nurse selected by the CLD staff/volunteer(s) to secure and administer treatment, including hospitalization, for the youth listed above. I do hereby agree to hold free from any and all liability all respective officers, employees, and members. I hereby on behalf of my child waive, release, and forever discharge any and all rights and claims for damages which my child may have or may not have accrue arising out of or connected with my child in any of the activities of the CLD.

Parent/Guardian Printed Name*

Date*

Signature of Parent or Guardian*

Phone

This field is for validation purposes and should be left unchanged.

College Prep Institute Workshop series Registration

Guardian (1)

Guardian (2)

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