Leadership Academy Application

Leadership Academy Application

Want to train to be a leader? Here's an educational application for a Leadership Academy. Form Preview
    • Registration Application  
    • Parent/Guardian Info  
    •  -
    •  -
    • Authorized Pickup  
    • Forms & Releases  
    • Informed Consent & Acknowledgement

    • I hereby give my approval for my child’s participation in any and all activities prepared by The Talented Tenth Boys Academy of North Carolina during the selected camp. In exchange for the acceptance of said child’s candidacy by  The Talented Tenth Boys Academy of North Carolina, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless The Talented Tenth Boys Academy of North Carolina 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  The Talented Tenth Boys Academy of North Carolina, 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.

    • Medical Release and Authorization

    • As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

      Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

      Permission is also granted to The Talented Tenth Boys Academy of North Carolina and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

      Release authorized on the dates and/or duration of the registered season.

      This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

    • Liability/Photo/Video Release

    • I, as the registered am 18 or over, or I am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered camper to attend The Talented Tenth Summer Academy of North Carolina and consent to its Discipline Policy and also do hereby release The Talented Tenth Summer Academy of North Carolina from any and all liability or responsibility due to any injury that he/she/I may incur as the result of, or arising in any way from participation in activities at or under the direction of The Talented Tenth Summer Academy of North Carolina. I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of The Talented Tenth Summer Academy of North Carolina to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I understand that The Talented Tenth Summer Academy of North Carolina only carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from treatment of injury or illness. I furthermore understand The Talented Tenth Summer Academy of North Carolina often takes photographs or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of The Talented Tenth Summer Academy of North Carolina. The Talented Tenth Summer Academy of North Carolina will not identify me or my child by name, or release any other personal information without additional written permission from me.

    • BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

    • Reload
    • Clear
    •    
    • Should be Empty: