BelieveIn Me Foundation Inc. Football & Cheerleading Educational Community Awareness Event Registration Form 2022

Child 1

Age

First Name

Middle name

last name

Gender

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

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

Parent/Guardian #2

First Name

lastname

ms. mrs. mr. other

street address

town/city

state

zip code

home phone

work phone

cell phone

fax

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?

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

if yes, explain

Is your child allergic to any type of food or medication?

if yes, explain

Does your child require a special diet?

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?

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).

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BelieveIn Me Foundation Inc. Football & Cheerleading Educational Community Awareness Event Registration Form 2022

Child 1

Child 2 (if applicable)

Parent/Guardian - Contact Information

Parent/Guardian #1

Parent/Guardian #2

medical release information

insurance information

photo release

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