Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Which of the following best describes the student's race/ethnicity?

African Ancestry (Black)

Asian/Pacific Islander

Latino

European Ancestry (White)

Other

Does you child have an IEP or 504 Plan? *

None

IEP

504

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Parent Phone *

(###)

###

####

Alternate Phone

(###)

###

####

Program Consent *

I certify and represent that, as parent/guardian for the above child, all registration and release information provided is true. I hereby represent that I have authority to bind and sign on behalf of all parent/guardians of the above participant(s). As parent/guardian, I voluntarily consent for my child to participate in the Destiny Academy at Bible Way Christian Center. With my signature, I hereby release and hold harmless the sponsors, promoter, Bible Way Christian Center and all other persons and entities associated with Destiny Academy and events from any and all injury by the participant(s) indicated. Furthermore, I hereby grant full permission for all the foregoing to transport the above participant(s) upon request. I understand that the most reasonable care will be provided to the above participant in the event of injury or illness during any Destiny sponsored activity and authorize emergency medical care should it be needed.