Event Registration
2017 Y.E.S. Summer Workshops
07/01/2018 09:30 AM - 07/21/2017 01:00 PM CT
* Parent First Name:
* Parent Last Name:
* Parent Address:
* City:
* State:
* Zip Code: -
* Parent Phone:
* Parent Email:
* PHOTOGRAPH CONSENT WAIVER:I understand that Jewels Academy may photograph my child individually or in a group setting. I understand that photos may be used in brochures, websites, newspapers, presentations, and television spots to further publicize the mission of the organization. I give full consent for these and similar uses of my child's photographic likeness, waiving any liability for Jewels Academy's Y.E.S. or its directors or employees. Choose YES for consent to take pictures or No to exclude your child from any pictures. Yes
What is the household income where the student resides? (This question links to grant funding)
Please list any allergies (Food or Other).
* Number of Attendees:
Mobile Provider: Sprint
If you have a coupon, please enter code here (case sensitive):      
Relation of Registrant to Attendees:
* Waiver Statement:

EMERGENCY MEDICAL AUTHORIZATION:  I understand that in the event of accident or illness, every effort will be made to contact parent/guardian immediately.  If parent/guardian cannot be reached, I authorize Jewels Academy to obtain emergency care for my child.  Type parent's name below.


Yes, I agree
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