Participant Registration Form

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New Beginnings' Registration Form

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Parent's Name: *

Address: *

Telephone Number: *

E-mail address: *

Name of Designated "Point Person" who will communicate with the Center's staff. *

Preferred method of communication: *

Student's Name: *

Student's Grade: *

Student's School: *

Student's "S9" information or virtual school log-in: *

Allergies: *

Emergency Contact: *

Comments/Things we may need to know: *

Captcha (spam protection code) *

By submitting this form, I am acknowledging that I give consent for my child to enroll/participate in New Beginnings Educational Center (New Beginnings) After-school Tutoring and Mentoring Program (Program). I understand as part of this Program, my child will be tutored during the day by an adult volunteer. I also give permission for my child's photo, video, sound recording, creative works and name to be used in and for promotion of New Beginnings' services and programs. Further, I grant permission for my child to receive any medical attention deemed necessary by New Beginnings' staff, their partners and/or volunteers for injuries or sickness that occur during Program sponsored activities. I will be responsible for any and all medical costs. I will not hold New Beginnings' staff, partners or volunteers liable for any injury or damage received by my child while he/she is transported or while engaging in Program sponsored activities. Lastly, I hereby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

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“Everything can be taken from a person except his education.”

- Anonymous