Section 1 of 4

Student & Parent Information

Please complete all required fields accurately. A confirmation will be sent to the parent email within 48 hours of submission.

Parent / Guardian email address *

Student details

Student's full name *

Age *

Grade *

Student's phone number *

High school attended *

T-shirt size *

Parent / Guardian details

Parent's full name *

Parent's cell phone *

Program eligibility

Does your scholar have an IEP? *

Yes No

Is your scholar on the GVRA caseload? *

Yes No

Transportation

Will your scholar need transportation to and from the Future Focus Conference? *

Yes — I need transportation provided No — I will drop off and pick up my child at Morrow Center @ Southlake Mall

Transportation details Drop-off: 8:00 AM – 8:30 AM | Pick-up: 2:30 PM
Location: Morrow Center @ Southlake Mall
Transportation is provided via sprinter van and will pick up at your home address.

Home address for pickup *

Health & wellness

Does your scholar have food allergies? *

Yes No

Please describe food allergies *

Does your scholar have any special medical or physical conditions? *

Yes No

Please describe the condition(s) *

Scholars will be required to walk extensively outdoors and on field trips. They must be independent and able to feed themselves, use the restroom, and follow instructions without additional help.

Can your scholar perform these tasks without assistance? *

Yes, my scholar can participate independently No — additional support will be needed

Section 2 of 4

Waivers & Consents

Please read each document carefully before indicating your consent.

Waiver of liability

Waiver of Liability & Hold Harmless Form

I give my scholar permission to participate in the Future Focus Conference organized by the Ringer Center of Excellence, Inc. I agree that my scholar will observe and obey all rules and warnings and further agree that he/she will follow oral instructions given by the Ringer Center staff and employees during the week of the Future Focus Conference. I assume full responsibility for my scholar's injury, loss, or damage arising out of participation in the Future Focus Conference. The Ringer Center is not responsible for any loss or stolen goods. I agree and acknowledge that I am under no pressure to sign this agreement and that I have been given a reasonable opportunity to review it before signing. I have read this document and understand it. I further understand that by signing this release, I agree to the above statements.

Do you consent to the Waiver of Liability & Hold Harmless Form? *

Yes, I have read and consent to the waiver No, I do not consent

Media release

Media Release & Consent

I, the parent/guardian of the above-named student, hereby grant permission to Ringer Center of Excellence, Inc. to photograph, video record, and/or otherwise capture the likeness, image, voice, or participation of the student during the Future Focus Conference. I understand that these materials may be used for educational, promotional, marketing, and informational purposes in print or digital formats, including websites, social media, presentations, and reports. I acknowledge that no compensation will be provided and that all such media shall remain the property of Ringer Center of Excellence, Inc. This consent is given voluntarily and may be revoked in writing at any time.

Do you consent to the Media Release? *

Yes, I consent to the media release No, I do not consent to media release

Section 3 of 4

Emergency Contacts

Please provide two different emergency contacts. These should be people other than the registering parent/guardian who can be reached if needed.

Emergency contact #1

Full name *

Relationship to student *

Phone number *

Email address *

Emergency contact #2

Full name *

Relationship to student *

Phone number *

Email address *

Section 4 of 4

Parent Signature

By typing your name below, you are electronically signing this registration form and confirming that all information provided is accurate and complete.

Your typed name constitutes a legally binding electronic signature of consent for all sections of this form, including the Waiver of Liability and Media Release.

Signature — type your full legal name *

By typing your name you agree to the terms and conditions of this form.

Date *

Thank you!

We are so excited to have your child participate in the Future Focus Conference.

A confirmation email will be sent to within 48 hours.

We look forward to a fun, educational, and memorable experience!

— Ringer Center of Excellence, Inc.