[vc_row][vc_column][vc_column_text]Please enable JavaScript in your browser to complete this form.Child's Full Name *FirstMiddleLastChild's Date of Birth *Gender *FemaleMaleChild's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName of child's school (2019-2020 School Year) *Child's Grade (2019-2020 School Year) *Parent or Legal Guardian's InfoParent's Name *FirstMiddleLastPhone Number *Email Address *EmailConfirm EmailWould you like to add contact info for another parent? *YesNoParent's Name *FirstMiddleLastPhone Number *Email Address *EmailConfirm EmailMedical and Emergency Contact Information Please provide emergency contact information for 2 additional adults (must be over age 21 and considered close relatives of the parent and child). Please list all known allergies and medical conditions *If none, type "N/A"Please list all known physical limitations, behavioral concerns, or other important information about your child. *If none, type "N/A"Name of Emergency Contact 1 *FirstLastRelationship to Child *Phone *Please provide active phone number of emergency contact 1. Alternate Phone Number Please provide active phone number of emergency contact 1. Name of Emergency Contact 2 *FirstLastRelationship to Child *Phone *Please provide active phone number for emergency contact 2. Alternate Phone Number Please provide active phone number of emergency contact 1. Pick Up/Drop Off List Please list names other than the child's parent, that you allow permission to pick up and drop off for arrival and departure. Name *FirstMiddleLastPhone *Name FirstMiddleLastPhone Would you like to add more names to the pickup list?NoYesAdditional Names for Pick Up/Drop Off List *Must add name and phone number to be valid.DESIRED START DATEDesired Schedule? *MondayTuesdayWednesdayThursdayPlease check all requested days.Additional InformationPlease list the full names of this applicant's siblings attending The Learning Hub I certify that the information that I've submitted is accurate *Yes, I agree**MEDIA RELEASE: I hereby grant permission to the Jackson Medical Mall Foundation (JMMF) and its assignees and licensees to take photographs or videos of my child, and to make recordings of their voice for the research or promotion of JMMF programs, events, and services. Unrestricted usage: I give unrestricted permission for images, videos, and recordings of my child to be used in print, video, digital and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and that these images may be used without further notifying me. I understand that uses of the images, videos and recordings will be in good taste in alignment with JMMF publication standards, and in the best interest of my family. This release expresses the complete understanding of the parties. I further understand that JMMF is not liable to pay royalties or any form of compensation as a result of my child’s appearance, voice or likeness in aforementioned pictures, videos, or recordings. *Yes, I agreeNo, I do not agree**LIABILITY WAIVER: I understand my child’s name(s) will not be published. I hereby assume all risks and hazards incidental to the conduct of the activities at Jackson Medical Mall and transportation to and from the activities. My Child is fit for the program(s) in which I have enrolled him/her. I hereby release and shall defend, indemnify and hold harmless Jackson Medical Mall Foundation and it’s program staff (JMMF) from every claim and any liability that I or my child may allege against JMMF (including reasonable legal fees and costs) as a direct or indirect result of injury or death to me or my child because of my child’s participation in any Jackson medical foundation programs , whether caused by the negligence of JMMF or others to the maximum extent permitted by law. I promise not to sue JMMF on my behalf or on behalf of my child regarding any claim arising from or related to my child’s participation in any Jackson Medical Mall Foundation program(s). I acknowledge that, by signing this document, I am releasing Jackson Medical Mall, Jackson Medical Mall Foundation, and their representatives, agents, employees, volunteers, members, sponsors, promoters, and affiliates from liability, and that I am giving up substantial legal rights. this sign up and release form is a contract with legal and binding consequences and it applies to all activities in which my child engages during The Learning Hub at Jackson Medical Mall, regardless of whether such activity is a part of a formal program. I have read this release carefully before signing. I understand what this release means and what I am agreeing to by signing. *Yes, I understand*INSURANCE & FINANCIAL RESPONSIBILITY: I understand that no insurance coverage for participants in these activities is provided by the Jackson Medical Mall Foundation. By registering for this program, I understand and agree that a fee of $25 will be assessed each month and that the first month's payment is due upon registration. I understand that if a portion of the program is unable to be completed due to unforeseen circumstances under responsibility of the Jackson Medical Mall Foundation that no refunds or proration will be given for any other reason. Yes, I understandSignature *Clear SignatureDrag your mouse to sign your name or write your name with your finger (if using a touchscreen device) to sign the form.EmailSubmit [/vc_column_text][/vc_column][/vc_row]
