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Youth Date of Birth
Month
Day
Year
Youth Grade
5th
6th
7th
8th
FREE or REDUCED Lunch
Yes
No
I understand that my household information is collected to support funding so programming can remain free for students, and my personal data will not be shared.
Yes
No
I certify all information and answers provided are true and complete to the best of my knowledge.
Yes
No

Liability Waiver

I hereby certify that my child(ren) is/are in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by Center 360. I acknowledge that Center 360 will not assume any responsibility or liability for personal injury or damages caused by the injury.


In exchange for the acceptance of said child’s candidacy by Center 360, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Center 360 and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected program sessions.


In case of injury to said child, I hereby waive all claims against Center 360, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessor of premises used to conduct the event. There is a risk of being injured that is inherent in all activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.


In the event Center 360 is unable to reach a parent, guardian or any emergency contact, I hereby give permission for my child(ren) to be transported to the nearest hospital for treatment in case of an accident or emergency. I hereby further authorize(s) any of the staff or employees to provide for, approve and authorize health care at hospital.

Photo/Video Release

I hereby grant and authorize Center 360 the right to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of my child(ren) to be used in and/or for identification as well as legally promotional materials and digital communications. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of and will not be returned.

School Liaison & Pick-Up


I allow Center 360 staff and coaches to communicate with school personnel about relevant information regarding my child’s work at school and his/her mental and physical health and well being. Center 360 staff and coaches will request copies of quarterly progress reports, report cards, and conduct weekly school and class visits of my child. I hereby agree on behalf of myself, my heirs, legates, executors, administrators, and personal representatives, to release and hold harmless all staff and coaches, Center 360, my child's home school and school personnel, and any and all other persons and organizations assisting Center 360, from liability for any communication with school personnel about my child.


I allow Center 360 staff and/or coaches to transport my child to and from school and Center 360 activities as needed. I hereby agree on behalf of myself, my heirs, legates, executors, administrators, and personal representatives, to release and hold harmless all staff and coaches, Center 360, my child's home school and school personnel, and any and all other persons and organizations assisting Center 360, from liability for transportation of my child.

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Registration Fee
$50

Registration Fee covers program activities and snacks for the 2025 - 2026 school year.

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