The3PointFoundation Program Application
Aplicación Para El Programa The3PointFoundation
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What school does your child attend? *
Nombre de Escuela
Which program does your child want to participate in? *
¿Tu hijo quiere participar en cual programa?
STUDENT INFORMATION
Información de Estudiante
Student's First Name: *
Primer Nombre de Estudiante
Student's Last Name: *
Apellido
Student's Gender: *
El Sexo de Estudiante
Student's Race: *
Student's Date of Birth: *
Fecha de Nacimiento
MM
/
DD
/
YYYY
Student's Current Grade: *
Grado de Estudiante
Student's BPS ID Number: *
Student's Address: Street *
Dirección de Casa: Calle
Student's Address: City *
Dirección de Casa: Ciudad
Student's Address: Zip Code *
Dirección de Casa: Código Postal
Student's Email Address: *
Correo Electrónico de Estudiante
Student's T-Shirt Size *
Talla de Camisa
PARENT/GUARDIAN INFORMATION
Información de Padre/Guardián:
Full Name of Parent/Guardian: *
Nombre de Padre/Guardián:
Relationship to Student: *
Relación al Estudiante
Lives with Student? *
Vives con Estudiante?
Parent/Guardian Phone Number (123-456-7890) *
Número de Contacto (123-456-7890)
Can this number receive text messages? *
¿Este número puede recibir mensaje de texto?
Parent/Guardian Email Address:
Dirección de Correo Electrónico
ACTIVITY AND TRIP RELEASE STATEMENT:
I give permission for my child to participate in all 3Point activities, whether athletic or extracurricular and including trips away from the premises at which the program is regularly conducted; and I release 3Point, its employees, officers, directors and agents from liability to me or my child for any loss or damage sustained by me, him or her, or for any injury to him or her or his or her property, whether that occurs while he or she is at the program location or elsewhere.
PHOTOGRAPHIC RELEASE
I agree, without compensation, to permit 3Point its agents, assigns, employees, and students to use my child’s photographic image, likeness or audio for the use and benefit of The3PointFoundation in its publications and other promotional material. This release shall be effective in perpetuity unless specifically revoked in writing.
RELEASE
I recognize that basketball and dance are strenuous activities and that there is some risk of injury. I also certify that my child is medically cleared to engage in strenuous physical activities including basketball and dance. In consideration for my child’s attendance and enrollment in 3Point, I release 3Point and/ or its teachers, staff, administrators, trustees, directors, and officers from any and all claims of any nature that we ever had, now have, or that may arise in the future, relating to or arising out of my child’s attendance or enrollment in 3Point, including the maximum extent permitted by law. Further, I agree not to bring any claims against The3PointFoundation and/ or its teachers, staff, administrators and trustees, directors or officers relating to or arising out of my child’s attendance or enrollment in 3Point, to the maximum extent permitted by law. I agree to indemnify The3PointFoundation for its expenses and costs, including reasonable attorney’s fees, if we violate this agreement and bring claim against The3PointFoundation or its teachers, staff, administrators or trustees, directors or officers. We agree that the terms of this paragraph shall be binding upon us personally, as well as upon all members of our family, and our and their heirs, successors, assigns, and legal representatives. Massachusetts’ law governs the validity, construction and administration of this contract.
PERMISSION TO OBTAIN MEDICAL TREATMENT
I understand that The3PointFoundation will not be responsible for medical expenses in connection with my child. In the event of injury or illness, I give 3Point permission to provide or obtain medical care in the event that it is unable to contact me or the Emergency Contact person provided below.
What are your child's transportation plans? *
Please list the names of people who have permission to pick up your child. *
Emergency Contact's Full Name: *
Contacto de Emergencia Nombre
Emergency Contact's Phone Number: *
Numero de Teléfono
Can this number receive text messages? *
¿Este número puede recibir mensaje de texto?
Emergency Contact's Email Address:
Direccion de correo electronico
Does the student have any allergies? *
¿Tu hijo tiene alergias a algo?
If yes, please describe any allergies the student has:
Por favor explique si tu hijo tiene alergias a algo
Does the student carry an Epi-Pen? *
¿Su hijo tiene y trae un Epi-Pen?
Is there any conflict that would prevent your child from attending the entire program? *
¿Hay conflictos que podrían prevenir a tu hijo a atender el programa entero?
If yes, please explain:
Por favor explica, si ha prevención
Parent/Guardian Signature (Type Full Name) *
Firma de Padre/ Guardian
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