BelieveIn Me Foundation Inc. Football & Cheerleading Educational Community Awareness Event Registration Form 2024 Child 1 Age First Name Middle Name Last Name Gender Select Male Female School Name Grade Date of birth Street Adrress Town/city State Zip Code Child's Cell Phone Child 2 (If Applicable) Age First Name Middle Name Last Name Gender Select Male Female School Name Date of birth Grade Street Ardress Town/city State Zip Code Child's Cell Phone Parent/Guardian - Contact Information Parent/Guardian #1 First Name Last Name Ms. Mrs. Mr. Other Street Address Town/city State Zip Code Home Phone Work Phone Cell Phone Fax Email Parent/Guardian #2 First Name Last Name Ms. Mrs. Mr. Other Street Address Town/city State Zip Code Home Phone Cell Phone Work Phone Fax Email Employer Child Lives with: Medical Release Information Insurance Information Policy Number Name Of Health Insurance Provider Primary Physician Address Phone Hospital Preference Please List Any Medical Problems, Including Any Requiring Maintenance Medication (I.E. Diabetic, Asthma, Seizures). Select Yes No If Yes, Explain Is Your Child Allergic To Any Type Of Food Or Medication? Select Yes No If Yes, Explain Does Your Child Require A Special Diet? Select Yes No If Yes, Explain BY CHECKING THIS OPTION: I understand that the Football & Cheerleading Educational Community Awareness Event will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. How Did You Heared About Us? Select one... After School Program Website School Word of Mouth Flyer other Photo Release BY CHECKING THIS OPTION:I hereby give permission for my child to be photographed during the BelieveIn Me Foundation Inc. Football & Educational Community Awareness E vent. I understand the photos will be used to keep a journal of activities, to share during powerpoint presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspapers and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of BelieveIn Me Foundation Inc. Football & Educational Community Awareness Event. and its affiliates. The BelieveInMe Foundation Inc. and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. Children's photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). Submit