New Student Registration – Buy-Cobb, Inc.

Student Registration

1 Student Info

2 Parent/Guardian & Emergency Contact

3 Consent Authorization

4 Wavier & Release of Liability

Student Info
Name
First Last
Student's Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Student's Email
Gender
Grade Level
T-Shirt Size
Student Commitment*
I commit my time and intent to the 2020-2021 BUY-Cobb, Inc. Leadership Academy. I have reviewed the program dates and will uphold the attendance and behavior commitments as stated.
I agree
Behavior Commitment*
❖ I will remember at all times that I represent BUY-Cobb, Inc. Leadership Academy and that my behavior will be such that it will bring respect to the Leadership Academy, my family and to myself.
❖ I will maintain and/or improve my grades, work habits, cooperation, academics, and effort. I will ask for help, tutoring, or advice when needed.
❖ I will make a concerted effort to meet new individuals within the Leadership Academy and to broaden my friendships. I will exemplify consideration for others.

I agree

Parent/Guardian
Parent/Guardian 1
First Last
Parent/Guardian 1 - Email
Parent/Guardian 1 - Phone
Add a 2nd Parent/Guardian*
Parent/Guardian 2
First Last
Parent/Guardian 2 - Email
Parent/Guardian 2 - Phone
Emergency Contact
Emergency Contact - Name
First Last
Emergency Contact - Phone

Consent Authorization (Must be 18 years or older)
Photo Permission*
BUY-Cobb, Inc. Leadership Academy participants might be photographed occasionally during monthly Leadership Academy sessions and during other activities. If permission is granted, the participant’s photo and could be used in various communications and on social media (Website, Newsletters, Advertisements, Instagram, Facebook, Twitter, etc.) throughout the year. Permission to use the participant’s photo and information:
Attendence Commitment*
Because of our firm commitment to engage students, it is helpful for each student to be present at most if not all of our monthly Leadership Academy sessions. We have found that the students that attend monthly are more engaged and feel a sense of unity and community with the other students and the organization as a whole. For our planning purposes, it is helpful for us to know if your student can commit to being able to participate as a full member this year. Review the 2020-2021 Program Dates and determine if your student will be available to participate as a full member of the Leadership Academy by committing to 7-8 Leadership Academy sessions.

My student will participate at a Full Member level:

WAIVER AND RELEASE OF LIABILITY – PLEASE READ CAREFULLY
(Must be 18 years or older)
In consideration of the furnishing by the BUY-Cobb, Inc. Leadership Academy of services and/or equipment to enable my child to travel to and/or to participate in the above-references BUY-Cobb, Inc. Leadership Academy (hereinafter referred to as the “Programs”), I HEREBY AGREE AS FOLLOWS:

I fully understand and acknowledge regarding my child’s travel via the provided transportation to and from the Programs and activities which will occur during some of the Programs that: (a) both travel and/or activities have inherent risks, dangers and hazards, and such risks, dangers and hazards exist in my child’s travel via the provided transportation to and from the Programs, as well as my child’s participation in the activities which take place during the Programs: (b) the aforementioned risks, dangers and hazards may be caused by the negligence of the volunteers, employees, officers, members, or agents of BUY-Cobb, Inc. and the BUY-Cobb, Inc. Leadership Academy and/or the negligence of the participants, the negligence of unrelated third parties, accidents, breaches of contracts, forces of nature and/or other causes: (c) my child’s travel to and from the Programs and outdoor activities during the Programs may result in injury or illness, including, but not limited to, bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability: and (d) by my child’s use of the provided transportation to and from the Programs and/or participation in the actual activities during the Program; I, as parent, warrant that I am the child’s legal guardian and hereby agree to assume all risks and dangers, together with my child, and all responsibility for any losses and/or damages occurring to my child, whether caused in whole or in part by the negligence or conduct of the volunteers, agents, officers, members or employees of BUY-Cobb, Inc., BUY-Cobb, Inc. Leadership Academy, or by any other person.

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify BUY-Cobb, Inc. and/or the BUY-Cobb, Inc. Leadership Academy and its volunteers, employees, officers, members or agents from any and all claims, actions, or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my child’s travel via the provided transportation to and from the Programs and participation in activities which take place during the Programs. I specifically understand that I am releasing, discharging and waiving any and all claims or actions that I may have presently or in the future for the negligent acts, failure to act, or other conduct by the volunteers, employees, officers, members or agents of BUY-Cobb, Inc. and the BUY-Cobb, Inc. Leadership Academy.
Consent*
I HAVE READ THE WAIVER AND RELEASE OF LIABILITY AND BY SIGNING BELOW AGREE TO THE TERMS FOUND THEREIN. IT IS MY INTENTION TO EXEMPT AND RELIEVE BUY-COBB, INC. AND THE BUY-COBB LEADERSHIP ACADEMY FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OCCURING TO MY CHILD CAUSED BY THE NEGLIGENCE, OR ANY OTHER CASE, OF ANY PERSON OR ENTITY.
I agree.

director@buycobbinc.org

678-465-8994

Student Registration

Student Info

Parent/Guardian

Emergency Contact

Consent Authorization (Must be 18 years or older)

WAIVER AND RELEASE OF LIABILITY – PLEASE READ CAREFULLY

BUY-Cobb Links

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