Student's Name *
Grade Level of Student * 6th 7th 8th Mother or Guardian's Name *
Please make sure the address matches the billing address for the credit card. Thank you.
Phone * Email *
Name of Emergency Contact *
Relationship to the Student * Emergency Contact's Phone Number * Please list any medical concerns or restrictions
Participation Agreement and Waiver *
I hereby waive and release the San Gabriel Educational Foundation and the San Gabriel Unified School District, and all of their officers, agents and employees from and against any claims, suits, losses or related causes of action for damages including attorney's fees and court costs, that may result from injury and death, accidental or otherwise, during or arising from the child's participation in the SEF After School Academy and any resulting illness and/or injury, and I agree to indemnify and hold harmless them and all of their officers, agents and employees from and against any and all such claims. I recognize that the recreational events or activities being entered into by my child is of my own free will. I understand that if my child is injured, this waiver will be used against me and anyone else claiming damage in any legal action because of my child's injury. I hereby acknowledge that I understand and am familiar with the nature of the activities in which my child will participate at this facility , and affirm that my child is in good health and that my child does not have a physical or emotional condition, past or present, of which I am aware, which would in any way affect my child's ability to participate in the program. I also understand that I am responsible for immediate pick-up of my child upon completion of the event my child/children are registered in.
Emergency Medical Authorization *
In case of emergency, I give my permission for emergency medical treatment of my child and for transportation to such treatment.
Photo/Video Consent *
Photographs/ videos may be taken during the event. These photographs/videos may be used for future San Gabriel Educational Foundation promotional material. Please indicate whether you will or will not grant permission to use y our child's photo for these purposes.
Consent to participate *
Completion and submission of this form indicates you have read, understand, affirm and agree to the above statements.
Future Doctor's of America Course *
The cost of the course is $150/ student. This includes all fees and materials. The total amount must be paid before the application will be processed. Credit Card payments only.
Credit Card * Total