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Program Registration
Contact Information
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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First Name
Last Name
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Member Information
The following information is necessary for our records and the funding our organization receives. The answers you provide are completely confidential. Your cooperation in providing this information is both appreciated and necessary.
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Health & Emergency Information
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Consents & Acknowledgments
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In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by Truly Valued, Inc. to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery for my child as named above.
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I give permission for my child to utilize the transportation (if applicable) provided by Truly Valued, Inc. and to participate in all field trips provided / sponsored by Truly Valued, Inc
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Truly Valued, Inc. offers Prevention / Intervention Programs. These are prevention programs that encourage all members to make smart, positive, healthy choices in life. The programs strive for participants to; identify and resist peer and media pressure for involvement in negative behavior and understand the consequences of negative decision-making. Participants will gain understanding of the physical and social changes taking place in their lives, as well as improve decision-making skills, learn goal setting, problem solving and relationship building. I understand the purpose of these programs and give permission for my child to attend.
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I give permission Truly Valued, Inc. to take photos/video of my child and then to use these for publicity purposes and to meet grant reporting requirements.
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I give permission to release to Truly Valued, Inc. any school information such as: grades, behavior and any other school reports necessary to assist in their programming.
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I approve my child joining Truly Valued, Inc. and agree not to Truly Valued, Inc., its Board of Directors, Staff or Volunteers responsible and/or liable, and hereby RELEASE INDEMNITY AND HOLD THEM HARMLESS from liability for losses of any personal property and for injuries or by accidents suffered by my child at a Truly Valued, Inc. or in connection with membership, travel or participation, including any injury or loss caused by or claimed to be caused by the negligence, whether in whole or in part. I ATTEST that the information provided is true and accurate.