WYLA After School Program Application
Complete this form if you are interested in signing up for the Westside Youth Leadership Academy After School Program. Students must live in the South Chattanooga and Eastlake Area.
Is your child returning from last year? *
Name of person registering child(ren)? *
Are you the Parent/Legal guardian? *
Relationship to Child(ren) *
Address *
City, State *
Zip Code *
Contact Phone Number *
Emergency Contact and Phone # *
List students that will be participating, Name, DOB, School, Grade, and If there are any allergies or medications. *
Please Review the Release forms. - Transportation Release Form: I grant permission for my child to be transported by The Net Resource Foundation , Westside Missionary Baptist Church during the After School Program. - Permission to treat: I hereby permit group leaders, volunteers, staff members, and the like to call 911 and/or to contact a medical facility or physician to provide proper treatment to my child and that I will be responsible for all expenses arising in association with such treatment. - Indemnity and Waiver of Claim: I hereby acknowledge that as a condition of my child participating in this program, I agree to indemnify and hold harmless The Net Resource Foundation, Westside Missionary Baptist Church, its employees and volunteers from any liability, lawsuit, cost, expense or claim of any type whatsoever (including legal fees) for any harm, injury or death arising out of the above mentioned programs. - Permission to use photo: I release all rights to use of video and/or photography that maybe included in to the Community Foundation of Greater Chattanooga, Inc, The Net Resource Foundation, Westside Missionary Baptist Church its representatives and/or its’ employees. I also give permission to use, display, distribute, publish, and copy either digitally or by means of print whether by Internet, CD, magazine, brochure, newspaper, TV, or other types of media without restrictions. I also understand that my name may or may not be used with the video and/or photography taken of me or the video and/or photography in which I may be included. I also release the videographer/photographer and any agents associated with the videographer/photographer of any claims, demands, lawsuits, that may arise in connection with the video and/or photography taken. - Have you read and accept the release forms? *
Please type your name below if the information above is accurate to the best of your knowledge. *
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