Students Taking Action & Responsibility Today
Registration Form

Child's Name: ______________________________________________________ Birthdate: ___________________
Child's E-Mail Address: __________________________________________________________________________
Address: ______________________________________________________________________________________
Town: ______________________________________ ZIP: ______________ Home Phone: ____________________
School: ______________________________________________________________________ Grade: ___________
Mother: _____________________________ Home Phone: _________________ Work Phone: __________________
Mother's E-Mail Address: _________________________________________________________________________
Father: ______________________________ Home Phone: _________________ Work Phone: __________________
Father's E-Mail Address: _________________________________________________________________________
Physician: __________________________________________________________ Phone: _____________________
Health Insurance Co.: _________________________________________ Policy #: ____________________________
Allergies: _____________________________________________________________________________________
Persons to contact in case of emergency, (if we can not reach you) :
Name: __________________________ Home Phone: _________________ Work Phone: ___________________
Name: __________________________ Home Phone: _________________ Work Phone: ___________________
Name: __________________________ Home Phone: _________________ Work Phone: ___________________
Persons authorized to pick up your child :
Name: __________________________ Home Phone: _________________ Work Phone: ___________________
Name: __________________________ Home Phone: _________________ Work Phone: ___________________
Name: __________________________ Home Phone: _________________ Work Phone: ___________________
Parent's Signature: ___________________________________________________ Date: ____________________


Students Taking Action & Responsibility Today Consent, Authorization and Release Form 1) This Consent, Authorization and Release Form is for said minor, ______________________________________, who will here to for be referred to as "The Minor." 2) This Consent, Authorization and Release Form is provided to the Director and staff of START for children in the Los Angeles area. 3) This Consent, Authorization and Release Form is applicable to any and all such trips and activities connected with START. 4) The Minor has my consent to participate in all trips, activities and programs which s/he attends. There are no limitations or restrictions of any kind whatsoever on such participation unless this line is initialed __________ with an explanation attached. 5) The Minor has been instructed by me, and understands and agrees to comply with all rules, regulations and code of conduct established by the Director and the official instructions and directives of all authorized staff, volunteers and other agents of START. 6) You are expressly authorized to engage appropriate health care providers to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under circumstances. If you are not able to timely contact me for instruction, acting as my authorized agent and at my sole cost and expense. There are no exceptions or limitations or other special instructions in connection with the foregoing unless the line is initialed __________ with an explanation attached to this page. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. 7) Unless this line is initialed __________ and I have provided you with specific instructions, directions or other specific data to the contrary, attached to this page, you may assume that The Minor has no medical disabilities, allergies or other limitations of any kind whatsoever that might in any way limit participation. 8) I expressly release and agree to indemnify and hold START, its Director, and all authorized staff, volunteers and other agents, free and harmless from any and all liability, charges, claims, costs and expenses of every kind and nature whatsoever, including reasonable attorney fees in connection with the acceptance and participation of The Minor in said trips, activities and programs. The foregoing Release is without reservation of any kind except only for such acts or omissions on your part that arise out of your intentional or negligent wrongdoing and without fault of any kind on the part of The Minor, or on my part in failing to disclose pertinent information to you. 9) I represent to you that I have sole, full and legal power and the right to execute this Consent, Authorization and Release, and that you will rely on my representations. 10) If this Consent, Authorization and Release is signed by more than one person, all references of the singular shall include the plural jointly and severally. I DECLARE, UNDER THE PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA, THAT I HAVE READ AND FULLY UNDERSTAND THE IMPORTANCE AND EFFECT OF THE FOREGOING CONSENT, AUTHORIZATION AND RELEASE, THAT I HAVE OBTAINED SUCH ADVICE OF AN ATTORNEY AND OF A LICENSED PHYSICIAN AS I DEEMED NECESSARY, TO MY COMPLETE SATISFACTIONS, THAT I HAVE RETAINED A TRUE COPY OF THIS DOCUMENT.
Parent's Signature: _____________________________________ Relationship to Minor: ____________________
Signing Parent's Name Printed: _________________________________________ Date: ____________________