P.O.S.E. for Gains
Positive - Outcomes - Successfully- Emerging for Gains
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P.O.S.E. for GAINS
Student (First & Name) 
Address
Gender
Birth Date 
MM
/
DD
/
YYYY
Age
Ethnicity
Grade Level
School Name
Parent / Legal Guardian (First & Last Name)
Phone/ Cell
Email Address
Emergency Contact (First & Last Name)
Child Pick-up
If "other" was the answer above, please specify who you give permission to pick-up child.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by BRIDGE THE VILLAGE and affiliates during the selected camp. In exchange for the acceptance of said child’s candidacy by  BRIDGE THE VILLAGE and affiliates., I assume all risks and hazards incidental to the conduct of the activities and release, absolve, and hold harmless BRIDGE THE VILLAGE and affiliates, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against BRIDGE THE VILLAGE, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include but are not limited to, the risk of fractures, paralysis, or death.

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Media Consent

 

As a parent or guardian of this student, I hereby consent to the use of photographs/videotapes taken during the course of the school year for publicity, promotional, and/or educational purposes (including
publications, presentations, or broadcast via newspaper, internet or other media sources). I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.


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