Virginia Student Application Form

Assignment, Consent, and Release
This release is executed for ______________________ (Student's Name),*
Student's Name
by ______________________ (Parents Name) to SHINE For Girls.*
Parent's Name
I/We, the undersign, on behalf of ______________________ (Student's Name),*
Student's Name
and for those who would claim under, through, or for him/hereby:
Assign all right, title, and interest we may have in the photographs and/or films and/or likenesses of ________________________________ (Student's Name) produced by SHINE or TV, newspaper, or radio outlets during the period she is attending the SHINE Program.*

Yes
Student's Name:*
Consent that SHINE or TV, newspaper, or radio outlets may publish, or use said photographs and/or film and/or likenesses for itself, in a manner consistent with SHINE policies and procedures.*

Yes
I/We hereby waive any right that I/We may have to inspect and/or approve the finished product or press release that may be used in connection with the photographs, films, or likenesses.*

Yes
I/We represent and covenant that I/We have read and fully understand the above paragraphs and knowingly and voluntarily execute this ASSIGNMENT, CONSENT, AND RELEASE.*

Yes
Primary Parent/Gaurdian Electronic Signature*
Date*

MonthDayYear

Emergency Medical Care Form
Mother's Name: (if not applicable, please mark each space with a "-")*

First NameLast Name
Day Phone*

Area CodePhone Number
Father's Name: (if not applicable, please mark each space with a "-")*

First NameLast Name
Day Phone*

Area CodePhone Number
Emergency Contact*

First NameLast Name
Day Phone*

Area CodePhone Number
Chronic Medical Conditions (requiring ongoing care): *
Prescription Medicines (if used regularly):*
Family Physician:*
Health Care Provider:*
Date of Last Tetanus Booster:*

MonthDayYear
Please list any other health issues or concerns that mentors should be aware of: *
I am not aware of any medical conditions which would interfere with my daughter’s participation in this activity and I hereby grant permission for my child to participate in SHINE.*

Yes
I grant permission for my child to participate for the selected dates.*

Yes
Additionally, in case of emergency and if I/we cannot be reached, I, the undersigned parent of the above-named child, do hereby authorize the SHINE program mentors to seek medical attention deemed necessary, by qualified medical personnel, during the entire time that my child is participating in this program.*

Yes
I/we understand that I/we will be responsible for any medical charges incurred in the treatment of my child, in the case of an emergency, that are not covered by my family’s health insurance.*

Yes
Parent/Gaurdian Electronic Signature:*
Student Electronic Signature:*

Help Us SHINE On!

Donation$10.00

Donation$25.00

Donation$50.00

Donation$100.00

Signature
That's it! By digitally signing below, you confirm that you are a 5th, 6th, 7th, or 8th grade girl living in the Greater Washington DC area (including DC, Virginia, and Maryland). You also confirm that you have filled out the Press Release & Medical History / Emergency Contact forms above and have answered all of the questions truthfully.
Primary Parent/Gaurdian Signature:*
Date*

MonthDayYear
Should be Empty:

Student Application