Student Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

*

(###)

###

####

Mom

First Name

Last Name

(###)

###

####

Dad

First Name

Last Name

(###)

###

####

Other Guardian

First Name

Last Name

(###)

###

####

Picture Permission *

The Gate is requesting permission to take pictures during programming. Pictures may be used to promote Gate programs or posted to social media

I DO give consent for The Gate to use my student's picture to promote program activities

I DO NOT give consent for The Gate to use my student's picture to promote program activities

Please Check the following concerning COVID-19 Regulations: *

*all boxes must be checked for a student to attend The Gate*

I DO give consent for my student to enter The Gate’s facility and assume risk of potential illness related to COVID-19.

I DO give consent that The Gate is not liable if my student contracts COVID-19.

I DO give consent that my student will be required to wear a mask while inside The Gate’s facility unless eating or drinking.

I DO give consent that my student will adhere to social distancing requirements outlined by the CDC.

I DO give consent for my student to work alongside volunteers and The Gate Staff (adhering to social distancing guidelines outlined by the CDC).

Parent / Guardian Permission *

I have read and agreed to The Gate policies and regulations. I am granting permission for my student to ride the bus from Hamilton Middle School to The Gate. I will make arrangements for my student to be picked up from The Gate at 5:30PM.

Reservation *

Please note, because of strict guidelines from the state, all students are required to reserve their spots prior to coming to The Gate!

Please check this box confirming that you have or will reserve a spot for your student(s).