THA APPLICATION

Applicant's Information

First Name

Last Name

Applicant's Sex:

Male

Female

Applicant's Race

Date of Birth

Applicant's Phone

(###)

###

####

*Food/Environmental Allergies:

Please put "N/A" if no allergies

Are you receiving free or reduced lunch?

Yes

Have more than one Child for registration? please fill in the section below for a second youth. Otherwise, please scroll past this section in order to finish the remaining application

Applicant #2 Information

First Name

Last Name

Applicant #2 Sex:

Male

Female

Applicant #2 Race:

Applicant #2 Date of Birth

Applicant #2 Phone

Country

(###)

###

####

Applicant #2 Email

If applicant does not have an email address, put "N/A"

*Food/Environmental Allergies:

Please put "N/A" if no allergies

Are you receiving free or reduced lunch?

Yes

Continue Application Below:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Information:

Name:

First Name

Last Name

Relationship:

First Name

Last Name

Phone:

Country

(###)

###

####

CONFIDENTIALITY STATEMENT

I hereby sign this document declaring that I have been made aware of potential conversations and information that may be shared between the participants taking part in the Trinity House Academy program sessions and activities, which may be sensitive in nature. Any information, data, comments, actions, etc. of any type, communicated during the course of class will be kept in confidence by all participants, volunteers, facilitators, ministers and myself. I have also been made aware of the consequence of dismissal from the program and/or further action(s) that could potentially be brought against me if it is determined by program administrators that I have violated any level of trust or any part of this confidentiality statement. I declare with my signature that my “yes” is “yes” and my “no” is “no”, therefore I will abide by this statement during and after my participation in THA programming.

Name (Applicant):

Today's Date:

Parent/Guardian: Please complete below.

I hereby sign this document declaring that I am the parent or legal guardian of the applicant(s) above, and have been made aware of the potential conversations and information that may be shared between my daughter/son/applicant of legal guardianship taking part in the Trinity House Academy program sessions and activities, which may be sensitive in nature. As the parent/guardian, I understand that any information, data, comments, actions, etc. of any type, communicated during the course of class or Trinity House Academy activities and/or events will be kept in confidence excluding any information that is shared which is at the detrimental health of my child/applicant (listed above). In such case, Trinity House Academy has committed to notifying me as the parent/guardian immediately upon knowledge of such information.

Name (Parent):

Today's Date:

MEDICAL RELEASE FORM

I give my permission for the applicant(s) above to receive emergency medical treatment by Trinity House Academy staff, volunteers, etc in the event of a medical emergency.

In the event of an emergency, please contact:

Name:

Relationship:

Phone

Country

(###)

###

####

Family Physician

Our Hospital preference is:

Insurance Company:

Insurance Card Number:

Insurance Contact Number:

Medical Information & History:

Is the applicant currently on any medications? If so, please list and state when they should be taken and any potential side effects we may need to monitor during our time with the applicant. Does the applicant have any food and/or environmental allergies? If so, please state. Has the applicant been diagnosed with any mental/behavioral illnesses?

*Signature:

Date:

LIABILITY RELEASE FORM

This document as of the date signed below, intending to be legally bound documentation hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless Trinity House Academy including financial responsibility, and any of its employees or volunteers representing or related to the organization as regards to any Trinity House Academy class sessions, events and activities. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for any and all Trinity House Academy sessions, events and activities. The undersigned further agrees to abide by all the rules and regulations promulgated by Trinity House Academy and/or its affiliate groups and vendors throughout the program which includes any offsite events. By signing below, I forfeit all rights to bring a suit against Trinity House Academy for any reason. In return, I am able to participate in Trinity House Academy sessions. It is my responsibility to obey all safety precautions as explained to me in written or communicated verbally.

Printed Name (Applicant):

Date:

If applicant is under 18, a parent/guardian must complete the section below.

Printed Name (Parent/Guardian)

Date:

PHOTO/VIDEO RELEASE FORM

I grant Trinity House Academy, and its representatives the right to take photographs/videos of me while participating in Trinity House Academy classes and activities to be used for advertising and promotional purposes. I authorize Trinity House Academy, my permission to copyright, use and publish the same in print and/or electronically. I agree that Trinity House Academy may use such photographs/videos of me with or without my name for any lawful purpose, including but not limited to publicity, illustration, advertising, and Web content. I have read and understand the above:

Printed Name (Applicant):

Date:

If applicant is under 18, I expressly represent that I have authority, either as a parent or legally appointed guardian, to authorize and grant Trinity House Academy, my permission to copyright, use and publish the same in print and/or electronically photos or videos of the applicant to be used for Trinity House Academy purposes which include advertising and promotional purposes.

Printed Name (Parent/Guardian)

Date:

Line

Trinity House Academy, Indianapolis, IN 46268 * Founder & CEO: Yvette Williams * (317) 550-5125 * E-mail: trinityhouseacademy2008@gmail.com