DAD Registration Form
Register your child for DAD Initiative programing
Student: *
Your answer
Date of Birth: *
Your answer
Gender: *
Your answer
Race: *
Your answer
Grade of student *
Your answer
School *
Your answer
Student cell number(for text alerts - not required)
Your answer
Parent/Guardian *
Your answer
Email address *
Your answer
Address: *
Your answer
Home Number: *
Your answer
Cell Number: *
Your answer
Work Number: *
Your answer
Does your child have an IEP or 504 plan? *
Emergency Contact Name: *
Your answer
Relationship to Child: *
Your answer
Address: *
Your answer
Phone Numbers: *
Your answer
Name of Physician: *
Your answer
Address: *
Your answer
Phone Number: *
Your answer
Hospital: *
Your answer
Please check all that apply
Current medications (please list and send instructions *
Your answer
I realize that respect is mandatory; and I agree to adhere to D.A.D. discipline policies. I agree to attend every program I register for on time. I will respect the instructors, D.A.D. staff, guest speakers, classmates and myself, and will do what is asked of me. Failure to comply with this agreement is just cause for dismissal from the program. (Initial & date to accept) *
Your answer
I hereby do declare my child to be physically sound, having medical approval to participate in the activities of the program. My child has permission to engage in all prescribed program activities, unless otherwise noted. I agree to drop off and pick up my child on time.(Initial & date to accept) *
Your answer
EMERGENCY MEDICAL AUTHORIZATION: I authorize any representative of D.A.D. staff to seek medical attention for my child when immediate medical care is warranted by the circumstances and I cannot be reached, or if under the circumstances there is no time to attempt to reach me because of the nature of the injury or illness. I further authorize the health care professional selected by the agency to provide the necessary care and treatment for my child. (Initial) *
Your answer
PHOTOGRAPH/VIDEO AUTHORIZATION: I hereby give D.A.D., or their designated agent, permission to use photographs/videos of my child for publicity or professional services, and to use such photographs/videos at the discretion of the above program. (Initial) *
Your answer
INTERNET RELEASE: I hereby give my child permission to participate in Internet activities. (Initial) *
Your answer
AWARENESS PROGRAM: I agree to allow my child to participate in any awareness and prevention programs provided by program staff. The program may consist of hour–long sessions concerning: Self Esteem, Conflict Resolution, Chemical Dependency, Awareness of Peer & Social Pressure, Personal Hygiene, etc. (Initial) *
Your answer
In consideration of my child’s participation in the activities of the D.A.D initiative, I do hereby agree to hold free from any and all liability the agency, contracted persons or organizations, and its respective officers, employees and volunteers and do hereby for myself, my heirs, executors and administrators, waive, release and forever discharge any and all rights and claims for damages which I may have or which hereinafter accrue to me arising out of or connected with my child’s participation in any of the activities of the program. (Initial) *
Your answer
By signing below, I agree to all the terms above. (Name & Date) *
Your answer
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