Student Registration Application

Name*
First Last
Sex*
Ethnic Background (choose one)*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Student Phone*
Student Email*
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Parent/Guardian Phone*
Emergency Contact Person (name & number)*
Liability Waiver Agreement*
I hereby waive and release the Keeping Dreams Alive Foundation (KDA), its employees and/or facility from any and all liability for illness or injury incurred while attending our camps and/or advisory programs.
Media Release Agreement*
I hereby grant permission to use any interviews and photographs/video of my child for community-based promotional purposes.
Acknowledgement & Agreement*
I hereby understand by submitting this form, my parent and/or legal guardian acknowledges, understands, and approves all of the information provided.

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