Summer 2023 Advancement Academy Registration Form
Please complete this form by May 19, 2023. Should you have any questions, please contact Maureen Duncan at 765-393-8625 or 
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Student's First Name *
Student's Last Name *
Student's Grade *
Student's School *
Select T Shirt Size *
Select Youth or Adult Size *
Parent/Guardian Name *
Phone Number 1 (ex. 765-123-4567) *
Phone Number 2 (ex. 765-123-4567) *
Parent/Guardian Email Address *
Emergency Contact Name & Relationship to Student   *
Emergency Contact Phone Number (ex. 765-123-4567)  *
Does your student have any allergies? *
If yes, please list allergies: *
Is your student prescribed medications during school hours? If yes please list *
Select One: My student will *
Student Address *
By submitting this form, I hereby give the Minority Health Coalition of Madison County permission to use my child’s photo for publicity purposes. I also, waive the right to review the finished product that maybe used with the student's photo. I hereby give consent and permission for the Minority Health Coalition to access my student's school based performance data including test scores, grades, etc. *
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