Ambassador Registration Form
Thank you for completing this registration form. This form gives us contact, demographic and size information. There are also waivers that you'll have to sign for. If you have any issues with this form, contact Coach Kelli at 404-867-4626.
Date of Birth
Street Address / Apt #
Ambassador Mobile Number
Was your child a member of any L.E.A.D. programs last year?
What other mentoring program(s) are you a part of? (For example, Boys & Girls Club, Big Brothers Big Sisters, At Promise, etc.)
Benjamin E. Mays High School
Booker T. Washington High School
Carver High School
Daniel McLaughlin Therrell High School
Frederick Douglass High School
Maynard Holbrook Jackson High School
South Atlanta High School
Please enter School Name
APS Student ID Number
If no provider, type N/A
Insurance Policy Number
If no provider, type N/A
Allergies (Food, Drug, Etc.)
If no allergies, type N/A
Fully Vaccinated (2 shots)
Partially Vaccinated (1 shot)
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone
This section gives us more info about parents, guardians and household make-up. Some of this info is used to help us write grants so we can fund our programs.
Second Parent/Guardian Name
Second Parent/Guardian Phone
Second Parent/Guardian Email
Does your child live in a single parent/guardian home?
Did at least one parent/guardian graduate high school?
Did at least one parent/guardian graduate college?
15,001 - 25,000
25,001 - 35,000
35,001 - 45,000
45,001 - 55,000
55,001 - 65,000
65,001 and over
This section collects size info for uniforms, cleats & other gear for your son.
T-Shirt Size (Adult Sizes)
Baseball Pants Size (Adult Sizes)
Batting Glove Size
Covid-19 Liability Waiver
While participating in events held or sponsored by L.E.A.D., Inc. | LEAD Center For Youth, (“LEAD”), consistent with CDC guidelines, participants are encouraged to practice hand hygiene, “social distancing” and wear face coverings to reduce the risks of exposure to COVID-19. Because COVID-19 is extremely contagious and is spread mainly from person-to-person contact, LEAD has put in place preventative measures to reduce the spread of COVID-19. However, LEAD cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with COVID-19.
LIABILITY WAIVER AND RELEASE OF CLAIMS:
I acknowledge that I am willingly allowing my son to engage in LEAD events and/or other activities (the “Activity”).
RELEASE AND WAIVER.
I hereby release, waive and forever discharge any and all liability, claims, and demands of whatever kind or nature against the LEAD and its affiliated partners and sponsors, including in each case, without limitation, their directors, officers, employees, volunteers, and agents (the “released parties”), either in law or in equity, to the fullest extent permissible by law, including but not limited to damages or losses caused by the negligence, fault or conduct of any kind on the part of the released parties, including but not limited to death, bodily injury, illness, economic loss or out of pocket expenses, or loss or damage to property, which I, my heirs, assignees, next of kin and/or legally appointed or designated representatives, may have or which may hereinafter accrue on my behalf, which arise or may hereafter arise from my participation with the activity.
I AGREE to and accept the above Covid-19 Waiver
I DO NOT AGREE to nor accept the above Covid-19 Waiver
General Waiver of Liability
In consideration for the willingness of L.E.A.D. ("Organization") to accept the individual signing below ("Participant"), as a participant in its program and/or participant/guest in L.E.A.D. programs and/or facilities, and for other good and valuable consideration, the receipt and sufficiency of which are acknowledged, Participant and/or Participant's parent(s)/guardian(s) does freely, voluntarily and without duress execute the following Release for and on behalf of him or herself and his or her heirs, successors, beneficiaries and assigns:
1. Waiver and Release. Participant and/or participants parent(s)/guardian(s) releases, forever discharges, indemnifies, and holds harmless Organization and its directors, officers, employees, volunteers, agents, vendors, partners, successors and assigns (collectively the "Released Parties") from any and all liability, claims, demands and causes of action of whatever kind or nature, either in law or in equity, arising out of or relating to Participant's activities at Organization ("Activities"), including but not limited to any claim for any bodily injury, personal injury, illness, death or property damage that may arise out of, occur during or result from the Activities, regardless of whether caused in whole or in part by an act or omission of a Released Party. Participant also understands that, except as otherwise agreed to by a Released Party in writing, the Released Parties do not provide any financial assistance of any kind, including but not limited to medical, health or disability insurance coverage for any participant in Organization's programs.
2. Medical Treatment. Participant releases, forever discharges, indemnifies, and holds harmless the Released Parties from any claim, demand or cause of action whatsoever arising out of or relating to any first aid or medical treatment rendered in connection with the Activities.
3. Assumption of the Risk. Participant understands that sports training and related activities may involve actions that can be hazardous to the Participant and have inherently dangerous risks. Participant hereby expressly and specifically assumes the risk of damage, injury, harm or death in connection with such Activities as well as travel to and from locations where Organization is performing its services.
4. Transportation Release. Participant releases, forever discharges, indemnifies and hold harmless the Released Parties from any and all liability, loss, costs or expenses sustained or incurred because (a) Participant was injured, died or sustained property loss or damage while being transported by any of the Released Parties, or (b) because Participant injured another person or damaged the property of another person while being transported by any of the Released Parties.
5. Media Release. Participant grants and conveys to Organization all right, title and interest in any and all photographic images and video or audio recordings made by or for Organization during Participant's participation in the Activities, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
6. Personal Property. Participant releases Organization from any liability or expenses sustained from the loss of any personal property sustained during the Activities.
7. Governing Law. Participant expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the state of Georgia, and that this Release will be governed by and interpreted in accordance with the laws of the state of Georgia.
I AGREE to and accept the above General Waiver of Liability
I DO NOT AGREE to nor accept the above General Wavier of Liability
L.E.A.D. Student-Athlete Rules of Conduct & Behavior Expectations
This is not an exhaustive list of rules and protocol. LEAD staff reserves the right to edit this document as needed.
1. LEAD's code of conduct is governed by the following core values. If what you are about to say or do doesn't line up with the following core values, then it's wrong:
Excellence (fulfilling expectations)
Humility (thinking of others more)
Integrity (doing what's right even when doing what's wrong seems more convenient)
Loyalty (showing unwavering, consistent support to a person or organization)
Stewardship (protecting an opportunity)
Teamwork (bringing your strengths and weaknesses to a team setting to accomplish specific goals)
2. Student-athletes are allowed three (3) absences per quarter. LEAD's quarters are as follows:
August, September, October
November, December, January
February, March April
May, June, July
3. Participation in a game/tournament is at the discretion of the coaching staff.
4. Players can be denied participation in practices, games and tournaments for disciplinary reasons.
5. Practice is necessary for team and individual success. Players are expected to attend every practice and game unless they are ill or injured. If that is the case, an email or text message should be sent to your coach ASAP. Any planned absences should be communicated at the beginning of the season.
6. Be on time. If practice starts at 5pm and you arrive to the field at 5pm, then you are late. Prepare accordingly so you can be at events on time. Arrival times for practice are at least 30 minutes before start time. Arrival for games and other events vary, so be sure to clarify this with your coach.
7. You are expected to maintain good grades. Classroom behavior and academic performance will be monitored frequently. LEAD staff will work with parents and teachers to provide support needed for student-athletes to do well in school. Maintaining satisfactory grades and good behavior in school are requirements to maintain membership in LEAD.
8. It is the players responsibility to safeguard and properly care for all equipment/uniforms issued to him/her. All equipment/uniforms must be returned within 3 days of the end of the season or last day of participation. Players/Parents understand that he or she is financially responsible for all equipment/uniforms.
9. Any instance of violence including physical, verbal and/or social media directed towards another teammate or coach, or use of illegal drugs, performance enhancing drugs, alcohol or tobacco products or possession of firearms and other weapons will result in disciplinary action. Discipline will be at the discretion of the coaching staff and/or parents and will follow Atlanta Public Schools guidelines.
10. Displaying a respectful attitude towards coaches, parents, officials, spectators, and opposing players is expected at all times.
I AGREE to and accept the above Rules of Conduct & Behavior Expectations
I DO NOT AGREE to nor accept the above Rules of Conduct & Behavior Expectations
Data Consent Waiver
Because of your child’s participation in L.E.A.D. Programs, you are being asked to allow your child to participate in a program evaluation of after-school programming in the Atlanta Public Schools by SportUp, Inc. d/b/a UpMetrics, a partner organization of Laureus USA and L.E.A.D. Programs, with a mission to improve youth development outcomes. Before you give permission for your child to participate, please carefully read the following information regarding the purpose of the evaluation and intended risks and benefits. Feel free to ask as many questions as necessary so that you understand what is being asked of your child.
Purpose of Study:
The program evaluation intends to measure the program’s impact on youth development outcomes by reviewing students’ overall academic progress, attendance, wellness, and behavior in relation to program attendance. The evaluation will measure impact through a short survey and academic data collected directly from Atlanta Public Schools.
What your child will do:
We are asking that your child complete a short survey about positive decision-making. They will be invited to take the survey twice: once at the start of the season and once at the end. Please note that your child may skip any question that they wish. The survey should take no more than 10 minutes of your child’s time.
Risks of Participation:
There are no anticipated risks in this study.
Benefits of Study:
The evaluation will help us learn more about designing services to assist children in L.E.A.D. Programs.
Protection of Privacy:
Your child’s information will be kept strictly confidential and solely used for program evaluation purposes and will be de-identified in the final evaluation. Any personally identifiable information will not be released to other people or organizations.
Authorization to Release Data:
L.E.A.D. Programs, Laureus USA, and UpMetrics request your permission for Atlanta Public Schools to release information about your child’s academic record for the program evaluation. Information released may include, but is not limited to: Demographic information (Race/Ethnicity, Gender, Limited English proficiency, Grade Level), enrollment information (enrollment start date, enrollment start status, enrollment end date, enrollment end status, enrollment days), GPA, SAT Scores, SAT assessment date, Georgia Milestones Scores, Average Daily Attendance, In-school and Out of School Suspensions, Expulsions, Referrals, and Detentions. This information will be used for evaluating and designing services to better assist children and families in L.E.A.D. Programs.
I understand that agreeing to provide access to my child’s data is voluntary. I understand that I have the right to withdraw my child’s participation at any time by contacting Coach Kelli.
Yes - I authorize Atlanta Public Schools to release and share the above information with L.E.A.D. and the organization's impact evaluation partners in order to conduct evaluations of L.E.A.D.'s programs.
No. I do not authorize the release of my child’s information.
May we contact you?
Would you like to receive information about our organization, programs, services and events?
Yes, please add me to your communication list.