Request edit access
Destination College Registration 2017
Thank you for signing up for Destination College! We look forward to seeing you there.

Event Timing:
October 14, 2017
9:00 a.m. - 3:00 p.m.

Event Address:
UCLA

Questions? Contact us at 323-900-8718 or at etann@fulfillment.org

First Name:
Your answer
Middle Initial:
Your answer
Last Name:
Your answer
Email Address:
Your answer
Birthdate:
MM
/
DD
/
YYYY
Phone Number:
Your answer
High School:
What Organization are you from?
Grade:
Will your family be attending with you ? Please tell us how many (This includes Parents and younger brothers or sisters that need to be cared for)
Parent Names that will be attending
Your answer
Transportation:
Buses will be provided for students at the following school sites:
•Hamilton High School
•New Designs Charter School
•NOW Academy
Margaret Bloomfield
Garfield High School
ICEF Viewpark Preparatory School

Students who are part of (Wonderful Education, LAPD Cadet, C5LA, CDF or other orgs) should contact their organization for transportation details.

If you choose to drive on your own to UCLA, parking is $12 at Lot P8.

Do you require transportation to Destination College?
If you need transportation, select pick up/drop off location.
Participant Release of Liability and Waiver:
I/We, have reviewed the description of Destination College (the “Event”) and hereby allow my/our son/daughter to participate in the Event and grant permission for my/our son/daughter to participate in all activities while at the Event. I/We waive all claims against, release, acquit, discharge, and covenant to indemnify and hold harmless the Fulfillment Fund, UCLA, and their respective employees, officers, directors, consultants, representatives and affiliates (collectively, “Representatives”) for any injury, accident, illness or death occurring during or by any reason of the Event, including without limitation any transportation to or from the Event. I/We also assume full financial responsibility for all medical treatment provided during or as the result of the Event, including without limitation ambulance transport, emergency services personnel, hospital expenses, physician and pharmaceutical good and services. Pursuant to the provisions of the Family Code Section 6910, I/we hereby authorize the Fulfillment Fund and all Representatives of the Fulfillment Fund to consent to or sign any waiver or release required for medical treatment of our son/daughter as recommended by a licensed physician or paramedic. I/We hereby authorize any hospital which has provided treatment to the above named minor pursuant to the provision of the Family Code Section 6910 to surrender physical custody of such minor to the Fulfillment Fund or any Representative of the Fulfillment Fund upon the completion of treatment. This authorization is given pursuant to Health and Safety Code Section 1283. It is understood that all reasonable efforts shall be made to contact the undersigned prior to the rendering of treatment to the patient but that none of the above treatment shall be withheld if the undersigned cannot be reached.

I/We understand and voluntarily assume full and complete responsibility for all risks associated with our son/daughter participating in this Event and for any injury or accident that may occur during such participation in this Event.

I understand that at this Event and related activities my child may be photographed. I agree to allow any photo, video or film likeness of my child for any legitimate purpose by the Event holders, producers, sponsors, organizers and/or their assigns.

Acknowledgement :
Student Electronic Signature
Your answer
Date:
MM
/
DD
/
YYYY
Parent Electronic Signature:
Your answer
Date:
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms