Grace Place School Student Registration
Job Readiness & Business Development Program
June 17 - July 24, 2024
Mondays - Thursdays 9:30am -12:30 p.m. 
Teens ages 13 - 18
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Student First and Last Name *
Student Phone Number
Student Email Address
Student Street Address, City, State, Zip *
Student Date of Birth *
Student Age *
Student Grade Entering *
Parent/Guardian First and Last Name *
Relationship to Student *
Parent/Guardian Phone *
Parent/Guardian Street Address, City, State, Zip *
Parent/Guardian  Email Address *
Parent/Guardian Employer
Parent/Guardian Work Phone
Parent/Guardian Work Email 
Please Provide Two Emergency Contacts, Name and Phone Number (numbers will be verified) *
Family Health Insurance Company *
Policy Number *
Health Problems/Allergies/Limitations of Student (Please type None if there are not any)  *
Please list any medications taken by Student *

My child can be given pain reducing medication (i.e. Tylenol, aspirin etc.) as deemed necessary by the school’s director or program coordinator. All medications, including non-prescription drugs must be turned into the program coordinator. 

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Required

List all the medications the student will be bringing 

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PARENTAL/GUARDIAN AUTHORIZATION: I hereby give permission for my child to attend Grace Place School Job Readiness Training Program as indicated above. I further certify that this health history is correct as far as I know and the person herein described has permission to engage in all prescribed activities, except as noted.

IN CASE OF EMERGENCY, I hereby give permission to the physician selected by the school to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child. I also hereby give permission to the school staff and/or school volunteer to inspect the contents of any or all of my child’s personal belongings, and to withhold and/or dispose of any improper or illegal contents. 

Type First and Last Name For Authorization

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MEDICAL RELEASE : In the event my child becomes ill or is injured while under Grace Place School’s supervision, I approve their authority taking the following steps in the following order: 1. Contact the parents/guardian of the child and follow his or her instructions. 2. In the event of an emergency when neither parent nor guardian can be immediately reached, contact the child’s physician and follow his instructions. 3. If the child’s physician cannot be immediately reached, a Grace Place School representative will use their own discretion in contacting a properly licensed practicing physician or the nearest hospital and follow their advice. If in the opinion of a properly licensed and practicing physician my child needs medical or surgical services which require my consent before being supplied and I cannot be reached, I hereby authorize, appoint and empower the director to furnish on my behalf such written or oral authorization as may be so required. Further, I release the director of Grace Place School and New Covenant Church and supporters from any liabilities which might arise from the giving of such authorization, it being my desire that my child be furnished with such medical or surgical services as soon as reasonably possible after the need arises. 

Type First and Last Name For Authorization

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PERMISSION & LIABILITY RELEASE 

I hereby grant permission for my child to attend Grace Place School’s Job Readiness Training Program. On behalf of myself, my heirs, executors, administrators and assigns, I hereby waive and release any and all rights and claims for damages which I may have against New Covenant Church and Grace Place School as well as any other person or organizations connected with the activity, their heirs, executors, administrators, successors, and assigns for any and all injuries which I and/or my child may suffer while attending and participating in school activities. 

Type First and Last Name For Authorization

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Grace Place School PHOTO RELEASE AGREEMENT 

YES I hereby authorize Grace Place School to release the name and/or photograph/or video of the person stated below for use in news releases, media publications and Internet. It is understood that photos/video will be used only to benefit the ministry of Grace Place School not for the personal gain of any individual.

NO I do NOT want my child photographed. 

Provide answer below. 

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Questions? Elizabeth Coldren, 954-600-3424 elizacoldren@graceplaceschool.org

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