Peer Registration Form

Peer Information

Child First Name

Child Last Name

Child's School Name

Child's date of birth

Current grade in school

Parent/Family Information

First Name

Last Name

Street Address

City

State

Zip

County

NOTE: If no email address type NoEmail@no.com

Phone Type

Mobile Phone

Home Phone

Work Phone

May we text you?

YesNo

By selecting yes, you agree to receive texts from Rowell Family Empowerment of Northern California at the mobile number you provided. Message and data rates may apply. Text STOP to unsubscribe from messages at any time. By subscribing, you agree to get text messages from Rowell about services we provide.

To view Rowell's Privacy Policy click the link below:
Rowell Family Empowerment's Privacy Policy

Family Role

Primary Language

Ethnicity

Health Care

Primary Care Doctor

Phone Number

Preferred Hospital, in case of Emergency

Does the child have any allergies?

Yes

Please list all known allergies with reaction here (including food and medication)

Does the child have seizures? (if yes, fill out Seizure Action Plan form)

Yes

Please provide information on type of seizure and if there are triggers that cause them.

Emergency Contact and authorized alternate pick up person #1

Contact's First Name	Contact's Last Name
Relationship to Attendee	Contact Number

Emergency Contact and authorized alternate pick up person #2

Contact's First Name	Contact's Last Name
Relationship to Attendee	Contact Number

Emergency Contact and authorized alternate pick up person #3

Contact's First Name	Contact's Last Name
Relationship to Attendee	Contact Number

There is a $50.00 fee per child. Please send check made payable to RFENC/SLATE with “Get SET” noted in the memo section. Money goes to cover facility costs, equipment rental, consumables, and admission fees. These costs are not covered by FNRC and are nonrefundable. This amount is due with the registration.

My child will be absent on the following day/s.

Photo Release Authorization

I the parent/legal guardian, grant Rowell Family Empowerment all rights to use images of my child or myself as indicated by the check boxes below. Rowell may use the images in any way deemed necessary, without limitation. I also irrevocably waive any right I may have to inspection or approval of any of the deliverables or uses contemplated in the Release. I, the parent/legal guardian hereby irrevocably release Rowell Family Empowerment from any liability, costs or expenses arising by virtue of the use of such things. This release shall be binding with restriction as to time or otherwise upon the family and his/her theirs, executors, legal representatives, successors and assigns, as the case may be.

Yes, I agree for photos to be taken of my childNo, I DO NOT want photos taken of my child

Informed Consent and Acknowledgement

I hereby give my approval for my child's participation in any and all activities prepared by the Get S.E.T. program. I assume all risks and hazards incidental to the conduct of the activities and representatives from any and all liability for injuries. In case of injury to said child, I hereby waive all claims against, Including all staff and all participants, and sponsoring agencies. If after 3 unexplained absences, I understand my child can be dropped from the program.

Yes, I agree

Contact Information