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BelieveIn Me Foundation Inc. Football & Cheerleading Educational Community Awareness Event Registration Form 2022
Child 1
Age
First Name
Middle name
last name
Gender
Select
Male
Female
School name
grade
date of birth
( as of june 30, 2011)
street address
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
grade
date of birth
( as of june 30, 2011)
street address
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
lastname
ms. mrs. mr. other
street address
town/city
state
zip code
home phone
work phone
cell phone
fax
email
occupation
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).
medical problem
required treatment
Should Paramedic By Called?
Select
YES
NO
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
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
BelieveIn Me Foundation Inc. Football I & C 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).
Thank you! Your submission has been received!
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