DREAMS REGISTRATION FORM
Let Us Dream is a non-profit 501(c)3 public charity organization, comprised of diverse programs the holistic development of the youth implemented by local community leadership. Its DREAMS, and DREAMS band projects are interpersonal and leadership skills development programs, designed for the holistic development of the middle school students. And DREAMS Pro is designed to lead adults towards their authentic success in life and profession
Email address *
DALLAS CHAPTER: Location: I​CEC​, (Kerala Association), 3821 Broadway Blvd​, ​Garland, TX 75043
Participant's Name: *
Your answer
Participant's Date of Birth: *
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Participant's Gender? *
Male
Female
Participant's Grade (by next school year) : *
6
7
8
Name of Participant's School and Address
Your answer
Parent(s) /Guardian (s) 2nd Email address
Your answer
Parent/Guardian 1 Mobile Number *
Your answer
Parent/Guardian 2 Mobile Number *
Your answer
Participant's Address: *
Your answer
Parent(s)/Guardian(s) Name: *
Your answer
Emergency contact if parent/guardian cannot be reached (authorized to release child to) Name, Address, and Phone number
Your answer
Name of person dropping off and picking up the participant (if it is not Parent/Guardian):
Your answer
MEDICAL INFORMATION: Physician’s Name​, Address & Phone Number:
Your answer
ALLERGY INFORMATION:
Your answer
NOTE: ANSWERS TO THE FOLLOWING CONSENT QUESTIONS HAS TO BE 'YES' FOR THIS REGISTRATION TO BE ACCEPTED.
CONSENT: I understand that pictures will be taken, including my child(ren)'s throughout the week. I hereby give permission for the pictures to be used to promote future D.R.E.A.M.S. projects. *
Required
CONSENT: I give permission for my child’s belongings to be searched, with my child present, when the D.R.E.A.M.S. team finds it necessary to protect the well-being of my child or any other participant. *
Required
​CONSENT: I understand that my child will participate in various activities throughout the week, some which may be strenuous. I would like for my child to participate in all activities *
Required
CONSENT: I release the D.R.E.A.M.S. team or any volunteer from all liability that may result from personal injury or injuries to property, resulting from any physical activity. *
Required
Does your child wants to be in DREAMS band?
DREAMS Band is run and managed by children with adult supervision (free for DREAMS members). Our senior band members help your child in their area of interest as a singer, musician, sound engineer, emcee, youth manager, etc.
Yes
No
Electronic Signature
By printing my signature below, I certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid as original.
Parent Signature (Print Full Name) *
Your answer
Participant's Signature (Print Full Name) *
Your answer
Dated *
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