Parents Name (Please Print)______

G.A.M.E. Time Registration Package

Parents Name (please print)______

Complete Mailing Address:______

City: ______State:______Zip:______

Email Address: ______Phone______Cell______

Child’s First Name / Child’s Last Name / Age / Sex / Race / T-Shirt Size

T-Shirt Sizes

 Youth Large Adult Small  Adult Medium  Adult Large

 Adult XLarge Adult XXLarge Adult 2XLarge  Adult 3XLarge

How We Collect Information: True Divine Community Development Inc., and its volunteers collect data through the submission of applications that are necessary to provide essential services, resources and assistance through our organization.

What We Do Not Do With the Information: Information about your financial situation, medical condition(s) and treatment(s) that you provide to us by application(s) is held in strictest confidence. We do not give out, exchange, barter, rent, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered client confidential.

How We Do Use Your Information: Information is only used as is reasonably necessary to obtain statistical data used in application(s)/request(s) for funding for community base programs, services and resources. By signing these documents you give TDCD permission to only release overall statistical data of the total population served.

G.A.M.E. TIME PARTICIPANT’S MEDICAL INFORMATION

Parent/Legal Guardian Name: ______

Address: ______City/State/Zip: ______

Phone: (best)______Email Address: ______

If I cannot be reached, please notify: ______Phone: ______

Medical Insurance Company: ______

Policy# ______Group # ______

Youth’s Name: ______Age: ______Allergies: ______

Currently on medication? Yes / No If Yes Give Diagnosis? ______

Youth’s Name: ______Age: ______Allergies: ______

Currently on medication? Yes / No If YesGive Diagnosis? ______

Youth’s Name: ______Age: ______Allergies: ______

Currently on medication? Yes / No If Yes Give Diagnosis? ______

Youth’s Name: ______Age: ______Allergies: ______

Currently on medication? Yes / No If Yes Give Diagnosis? ______

Note: If child is currently receiving medication, please ensure it is taken!

If an explanation is needed please explain: ______

______

Parent/Guardian Signature: ______Date: ______

PERMISSION SLIP

PLEASE COMPLETE ONE FORM PER FAMILY

My child(ren) ______, have my permission to accompany the G.A.M.E. Time Youth Leadership Mentoring Program on field trips during weekend and summer camp hours of operations.

______

Parent’s SignatureDate

Emergency Contact Number(s): ______

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PHOTORELEASE

The G.A.M.E. Time Youth Leadership Mentoring Program has my permission to photograph my child(ren).

______

Print Child(ren) Name

______

Parent’s NameDate

Note: Photos will be used for advertisement and fundraising purposes in support of the G.A.M.E. Time Youth Leadership Mentoring Program.

Release and Waiver of Liability

In consideration of being permitted to participate in “G.A.M.E. TIME” mentoring sessions, under True Divine CommunityDevelopment (TDCD), Inc.. the undersigned, for himselfor herselfand his or her child(ren) (the participant”), acknowledges, agrees and represents that IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE, HEREBY AGREES TO THE FOLLOWING:

I -The undersigned hereby waives, discharges, and covenants not to sue the TDCD, Inc., partners and sponsors, directors, officers, and agents (herein after referred to as ‘releases”); Releases all releases from all liability to the undersigned, his or her personal representative, child(ren). and next ofkin for any loss or damage, and any claim demands therefore on account of injury tothe person or property or any action resulting in death of the participant, whether caused by negligence of the releases or otherwise while the undersigned or participant is participating in “G.A.M.E. TIME” activities.

2.The undersigned, onbehalfofhimselforherselfand the participant. Herebyassumes full responsibility for and risk of bodily injury, death, or property damage due tonegligence ofall releases or otherwise while in, about, or upon the premises being leased by TDCD, Inc.

The undersigned further expressly agrees that the foregoing RELEASE AND WAIVERAGREEMENT is intended to be as broad and inclusive as is permitted by the law of theState ofAlabama.

The undersigned has read and voluntarily signs the release and waiver ofliability and indemnity agreement, and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement has been made.

I HAVE READ THIS RELEASE

Date: ______Parent’sName: ______
(Please Print)

Parent’s or Guardian’sSignature: ______
Emergency Contact ______Number(s):______

G.A.M.E. TIME RULES

G.A.M.E. Time t-shirts are to be worn (NO EXCEPTIONS) to all sessions and field trips.

Children ages 6-10 years old must be signed into all sessions and camp
No early drop off
No fighting
No profanity
No throwing
No food in the gym
No Horse-playing
No inappropriate touching
No telephone usage without permission
No running in the lobby
No hats, bandana, do-rags, or drugs, etc.,
No sandals or improper shoes on gym floor
No running on the bleachers
No one allowed in front office
Shoes must be worn at all times
No one allowed on school campus (with an escort/mentor)
No inappropriate clothing
No horse-playing in the restrooms
No refunds on snack machines
No beating on machines
Kitchen/dining hall off limits unless escorted by an adult
No recruitment for gangs
Jewelry should not be worn to sessions/events (Girls may wear studs and any necklace should be tucked inside clothing)

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship. I hereby acknowledge that my child will be transported by his/her mentor and/or G.A.M.E. Time Youth Leadership Mentoring Program or representatives while participating in the G.A.M.E. Time Youth Leadership Mentoring Program, and that such transportation is voluntary and at his/her own risk.

Parent/Guardian Signature______

Child(ren)’s Initials______

Date______

Used for funding and statistical purposes only:

What is your gross yearly family income:

 $0 - $20,000 $21,000 - $30,000

 $31, 000 - $40,000 $41,000 - $50,000

 $60,000 - $70,000 $71,000- $80,000

 $90,000 - $100,000 $101,000 and above

Parent/Guardian’s highest grade completed: ______

Parent/Guardian’s occupation: ______

What is total number in the household:

Adults ______(age 19 years and older)

Child(ren) _____ (age 0 – 18 years old)

Thank you