TRAVEL WITH CHAZ REGISTRATION FORM

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TRAVEL WITH CHAZ REGISTRATION FORM

At Travel With Chaz (TWC) we’re dedicated to helping reduce community violence and promote youth safety by offering fun, enriching, and impactful opportunities for self-expression and growth. Through our exciting programs, we provide experiences that inspire and empower, including:

Attending professional sporting events
High school and college campus tours
Overnight retreats
Boxing classes
Educational museum visits
Cruises
Broadway plays
And so much more!

Our programs are designed to be both fun and educational, allowing young people to build positive memories, develop new skills, and foster a greater sense of community.

Annual Membership Fee:

Only $25.00 per year
Financial assistance is available

Please fill out the registration form below to secure your spot in our programs.

Whether you’re signing up for yourself, your child, or someone else in your life, we look forward to welcoming you into the Travel With Chaz community!

¡Bienvenido a Travel With Chaz! Complete el formulario de registro para asegurar un lugar para usted, su hijo o alguien más en su vida.

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Our Co Locator Hub

We are located at Phipps Neighborhood Cornerstone 1680 Seward Ave, Bronx, NY 10473

If you have any questions, feel free to reach out to us:
Charles Benson
Phone: (646) 644-3521
Email: travelwithchaz@aol.com

Email *

Name / Nombre (Include preferred name if applicable) *

Date/Fecha *

YYYY

Birthdate / Fecha de nacimiento *

YYYY

Phone number / Numero de telefono *

Alternative phone number / Numero de telefono alternativo

Address / Dirección *

School (if relevant) /Escuela (si corresponde)

Grade (if relevant) / Grado (si corresponde)

List all known allergies / Enumere todas las alergias conocidas

Does this individual require any accommodations in order to participate TRAVELWITHCHAZ? If yes, please explain. / ¿Esta persona requiere alguna adaptación para poder participar en TRAVELWITHCHAZ? En caso afirmativo, explique.

TWC strives to build skills in youth. Which of the following skills/topics would you like to see addressed? / TWC se esfuerza por desarrollar habilidades en los jóvenes. ¿Cuál de las siguientes habilidades/temas le gustaría que se abordara? *

Creative expression / Expresión creativa

Emotional regulation / Regulación emocional

Healthy relationships / Relaciones saludables

Academic success strategies / Estrategias de éxito académico

Diet/healthy eating / Dieta / alimentación saludable

Alternatives to violence / Alternativas a la violencia.

Other:

Required

Name of Parent/Guardian (if applicable) / Nombre del padre/tutor legal (si aplica) *

Relation to participant / Relacion al participante *

Phone number / Numero de telefono *

E-mail address / Correo electronico *

TWC Media and Photo Policy

Travel With Chaz (TWC) maintains a Youth Group website and an iPage account where we periodically share photos and videos from our events. In addition, we may utilize bulletin boards, media platforms, and print publications to promote our programs and showcase highlights from various activities.

It is the policy of Travel With Chaz that any photos of children taken during events will never be published alongside names or other identifying information to protect their privacy.

Yes, you can use pictures and videos of my child. I hereby grant TravelWithChaz Yonkers, NY the permission to use my child’s likeness in photographs, video, and other media in any and all of its publications, including bulletin boards and website entries. I waive any right to royalties or other compensation arising or related to the use of the photographs or videos. / Sí, puedes usar fotos y videos de mi hijo. Por la presente, otorgo a TravelWithChaz Yonkers, NY, el permiso para usar la imagen de mi hijo en fotografías, videos y otros medios en todas y cada una de sus publicaciones, incluidos los tableros de anuncios y las entradas al sitio web. Renuncio a cualquier derecho a regalías u otra compensación que surja o esté relacionada con el uso de las fotografías o videos.

No—please do not print or publish photos of videos of my child online or in any publications. / No, no imprima ni publique fotos de videos de mi hijo en línea ni en ninguna publicación.

Permission and Release Form

1. Permission to Participate:
I/We hereby grant permission for the above-stated individual to participate in activities arranged by Travel With Chaz, and approved by its CEO (Charles Benson), Executive Vice President (Jennifer Benson), Committee, and/or Community Volunteer Partners from time to time.

2. Commitment and Behavior Expectations:
We recognize the importance of the commitment that he/she makes and that their participation as part of a larger community calls for responsible behavior. Therefore, I/We agree that if this child engages in behavior which, in the judgment of the adult leaders, is not in the best interest of the trip or event, our/my child or any member of the group may not be allowed to continue on the trip. In such a case, the parent or guardian on file would be required to pick them up.

3. Responsibility for Return Trip:
I/We will assume full legal and financial responsibilities for such a return trip.

4. Release of Liability:
I/We hereby release from any liability TravelWithChaz NYC, NY, and all of its personnel, employees, adult leaders, and representatives from any claims for unintended or unexpected accidents that may occur during participation in youth group events, or while traveling to or from said events.

5. Transportation by Private Vehicles:
In granting this permission and release, I/We specifically recognize that my child may, from time to time, be transported to events by private vehicles operated by advisors or volunteers, who are not acting as agents, employees, or representatives of TravelWithChaz.

6. Release of Liability for Private Transportation:
In such regard, I/We specifically release and will hold harmless TravelWithChaz, its officers, employees, agents, and representatives from any and all liability which may arise as a result of such transportation, whether or not organized by TravelWithChaz NYC, NY.

Agree / de acuerdo

Disagree / discrepar

Link to form of Payment here: Annual Fee $25.00

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