ASTT STUDENT REGISTRATION

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Student's Full Name *

Current Grade Level *

9th

8th

10th

11th

12th

Street Address *

Zip Code *

Phone Number *

Alternate Phone Number

Parent/Guardian Name *

Parent Guardian Email *

Parent/Guardian Phone Number

Emergency Contact Name *

Emergency Contact Number *

Relationship to child *

Please list any medical issues or allergies that may affect the student’s participation in the program. (Enter N/A for none)

By initialing, I confirm I am the Parent/Guardian of the student named above, and I authorize R3 Inc.-ASTT, in the event of an emergency, to seek, obtain and consent to treatment as deemed necessary by a licensed medical or healthcare professional.
*

By initialing, I give permission to R3 Inc.-ASTT for my child/student named above, to be photographed and/or videotaped for educational or promotional purposes.

Consent Statement

I hereby state that my child/student named above, is in good mental and physical health condition to participate in the activities provided by R3 Inc. -ASTT, including but not limited to all aspects of forums and sessions. I am fully aware that any activity creates the possibility of injury. I hereby release R3Inc.-ASTT, its employees, staff and volunteers from liability to the above named student, of the person claiming through him/her, arising from injury to the person or property of the above named student occurring while participating with R3 Inc.-ASTT, including any event sponsored or sanctioned by R3 Inc.-ASTT, and or travel to and from such activities.

I also understand that R3 Inc.-ASTT, has the right to deny admittance to any student not meeting the standards of the program as it sees fit. I also agree not to hold these parties responsible in the event that my child/student named above, engages in inappropriate conduct (including, but not limited to disruptive or volatile behavior in or out of R3 Inc./ASTT program, etc.) or becomes involved in any activity or with any persons not associated with R3 Inc.-ASTT, or its scheduled program and that R3 Inc.-ASTT, has the right to send the student home for inappropriate conduct.

By printing my full name below, I confirm I have read and agree with the Consent Statement. I further certify that the information contained in this application is correct to the best of my knowledge.

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