Explorers Academy Registration & Consent Form
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Email *
PERSON REFERRING PARTCIPANT
Name:
Agency:
Title:
Email:
Number:
Reason for referral?
PARTICIPANT INFORMATION
Youth First Name: *
Youth Last Name: *
Emergency Contact Name: *
Emergency Contact Phone Number: *
Address: *
City: *
State: *
Zip: *
Date of Birth: *
MM
/
DD
/
YYYY
Age: *
Social Security Number:
Gender: *
School: *
School ID:
Grade: *
Allergies: *
Other Medical Conditions:
Special Instructions:
Insurance: *
Name of Doctor:
Doctors Phone Number:
Name of Health Clinic/Hospital:
I herby give my child permission to participate in MissionSAFE and Safe City Dorchester at MissionSAFE (SCD) and all their activities, field trips, interactions with participating institutions, agencies, volunteers, mentors and organizations.                                                                              .                                                                                                          If not in school, pleas leave those lines blank. If you are over 18, you may sign your own form and fill out emergency and medical information.                                                                                                            .                                                                                                                  I authorize MissionSAFE, its staff and/or volunteers, to seek appropriate medical care and/or counseling for my child if he/she should become ill, be in crisis, have need or an emergency, and to intervene on his/her/their behalf, including receiving relevant information, institutions involving police, court, DYS, DCF. or other officials.                                                                                                    .                                                                                                                       I give permission for MissionSAFE to monitor my child's school grades and progress, including talking to teachers/counselors and accessing report cards, progress reports, in order to make its tutoring and support more effective during the school year, I give permission for MissionSAFE and SCD to take and use photographs, audio and video footage for program, publicity or fundraising purposes.                                                              .                                                                                                                                     I also agree to hold harmless MissionSAFE and all its programs, including SCD; its staff, officers, assigns, volunteers, and any and all individuals. organizations, agencies, or institutions giving space, hosting, transporting, working with, or participating with MissionSAFE in programs and activities in the event of illness, accident, injury or death of my child while coming to, participating in, o leaving from MissionSAFE programs.                                                                                                                      .                                                                                                           SIGNATURE IN PRINT of Parent/Guardian or Youth Aged 18+ *
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