2019 Online Registration - June 27 – June 30, 2019

01. Applicant Info

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02. Parental Guardian Contact Info

03. Emergency Contact Info

04. Physcian Contact Info

05. Acknowledgement

WAIVER of PARTICIPATION


I realize that all of the activities scheduled for this event inherently possesses the possibility of injury. The Spotsylvania Chapter of the NAACP, John. J. Wright School Park, Bragg Hill Family Life Center and the County of Spotsylvania do not provide accident insurance for program participants. I hereby understand that insurance coverage is advisable and that payment for any emergency medical, hospital, or physician treatment rendered for my son is my responsibility.

It is with full understanding of all items above that I give full permission for my son to participate in the Rites Of Passage Program. I understand that in the event my son requires medical/dental treatment while engaged in the Rites Of Passage Program, reasonable efforts will be made to contact me, however, if I cannot be reached, I hereby consent and give my full permission to the Spotsylvania Chapter of the NAACP’s sponsor as agent for me to obtain necessary medical attention in case of sickness/injury to my son. Also I understand that as a participant my son may be photographed or videotaped during program activities and these photos/videos my be used in promotional materials.

By enrolling my son in this program I hereby, for my dependent, waive and release any and all rights and claims against the Spotsylvania Chapter of the NAACP, John. J. Wright School Park, Bragg Hill Family Life Center and the County of Spotsylvania and its representatives, successors and assigns for any and all injuries suffered by my dependent during the programs provided. Additionally, I certify that my dependent is able to participate fully in all activities unless otherwise stated in writing to the Spotsylvania Chapter of the NAACP.

#1540-847-7637

Rites of Passage Young Men of Valor Rites of Passage Young Men of Valor Rites of Passage Young Men of Valor