Mail to: Rock Handball 86 Blue Thorn Trail San Antonio, TX 78256 USA
Child’s
Name:_______________________________________________ Gender: (circle one)
M F Birthday:_________________
Address:_________________________________________________________________City:_________________Zip:___________
Home Phone:_____________________________School:__________________________________________________Grade:______
Parent/Guardian
Name(s):_________________________________________________ Adult Jersey /
T-Shirt Size: S M L XL
XXL
I, the parent/guardian of the
above mentioned child, give the Rock Team Handball Program permission to seek
necessary medical attention in case of injury to my child. I agree not to hold the Rock Team Handball
Program, its employees, and/or the school/school district responsible in any
way.
Signature:__________________________________________________ *Email Address:
______________________________________________
*Main source of communication
will be through email.
City: Atlanta
Houston
Huntsville
San Antonio
Skill Level: Elementary School (grades 3-5) Child’s Ethnicity: Asian/Pacific Islander
Middle School (grades 6-8) Black/African American
We are seeking grant funding and would like the following
information. This data will only be
used in creating statistics and identifying companies that have grant
programs. Your individual data will not
be handed out to anyone outside the organization.
Income Level Per Year: up to $12,490 $12,491-$15,670 $15,671-$18,850 $18,851-$22,030 $22,031-$25,210 $25,211 or more
Number of people in your household: ___________Adults __________Children
Education level (circle highest level
obtained): GED HS diploma BA/BS
Masters PhD Other___________(e.g., grade 11).
Circle one: Single Parent Female Household Single Parent Male Household Two Parent Household
Is this child a foster child? Yes No
Employer(s):_____________________________________________________________________________________________
ROCK TEAM HANDBALL PROGRAM PHOTO/MEDIA
RELEASE FORM:
I hereby confer
to the Rock Team Handball Program, the unrestricted and irrevocable right and
permission with respect to the photographs/videos/recordings that he/she has
taken of me or in which I may be included with others:
a.
To copyright the same in
Rock’s name or any other name that may be selected;
b.
To use, re-use, publish
and republish the same intact or in part, separately or in conjunction with
other photographs, in any medium now or
hereafter known, and for any purpose whatsoever, including (but not by way of
limitation) illustration, promotion, advertising, and trade;
c.
To alter the same without
restriction, and;
d.
To use information in
connection therewith if he/she so decides including that which could be
personally identifying, including but not limited to: membership in certain organizations, etc.
I hereby release and discharge (ROCK) from all and
any claims and demands ensuring from or in connection with the use of the
photographs/videos/recordings, including any and all claims for libel and
invasion of privacy. I hereby waive any
right that I may have to inspect or approve the finished product or products or
the advertising copy or printed matter that may be used in connection therewith
or the use to which it may be applied.
I hereby consent that the videotapes, photographs,
motion picture film in which I appear, and/or audio recordings made of my voice
may be used by ROCK and their assigns or successors, in whatever way they
desire. Furthermore, I hereby consent
that such photographs, film recordings, and the plates and/or tapes from which
they are made shall be their property, and they shall have the right to sell,
duplicate, reproduce, and make other uses of such photographs, films,
recordings, plates, and tapes as they may desire free and clear of any claim
whatever on my part.
I hereby warrant that I am of full age and have every
right to contract for the minor in the above regard. I state further that I have read the above authorization,
release, and agreement prior to its execution, and that I am fully familiar
with the contents thereof. This release
shall be binding upon me and my heirs, legal representatives, and assigns.
If under 18 years of age, the
minor’s parent and/or guardian must sign below. IN
WITNESS WHEREOF I have hereunto set my hand,
In the State of
_______________, on the date of _________________
Minor’s name (please
print):_________________________________________ Parent or Guardian (please
print):___________________________________________
Signature:________________________________________________________
Signature:_____________________________________________Date:____________