2015 Registration – Terrell Christopher Gladney Memorial Academy

Student Name:*

First

Last

Gender:*

Male

Female

Birthdate:*

day

month

year

Height & Weight (approx.):*

School Name (2015-16):*

Interests/Hobbies/Gifts/Talents:*

If other specified above, please provide details:

Home Address:*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone (Parent):*

Area Code

Phone Number

Phone (Student):

Area Code

Phone Number

E-mail:*

Any Allergies or health concerns? If yes, please describe

Health Insurance/Doctor Info:

Would you like to support our program?:*

If yes, please indicate your desired form of support. Some options are listed below, but we welcome ANY additional methods of support you may have to offer. (Donation of items - snacks water, classroom materials (pencils/paper/binders), fitness equipment; Volunteer (During our daily program (leading a workshop, filming/photographing, reading, coaching, or general supervision) or as a chaperone for a field trip); monetary donation (to support our student leadership program (stipends, training materials), field trips)

Do you give authorization for photos/videos of your child to be taken and used for the purposes of marketing the TCG Summer Academy and its activities? *

Parent Name (Electronic Signature) This will serve as your electronic signature confirming your child's participation in our program:*

First

Last

Today's Date (To confirm your signature):

Send a copy of this message to yourself