Register for STRIVE - City Academy

Student Name*

First Last

Student Date of Birth*

Current grade in school*

Student Email*

Enter Email Confirm Email

Student Phone*

Student Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Current school*

School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

School Phone*

Fax

Counselor/Advisor's Name*

First Last

Counselor/Advisor's Email*

Counselor's Phone*

Parent/Guardian Name*

First Last

Relationship*

Parent/Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian Phone*

Parent/Guardian Email*

Enter Email Confirm Email

Commitment to Program*

I, the student, agree to the program commitment
I, the parent/guardian, agree to the program commitment

By checking this box, both parent/guardian and student agree to the terms of the class and commit to the following: • Attend each scheduled meeting • Arrive 15 minutes prior to the start of class • Arrive prepared with the required learning tools: o Homework materials or laptop

Do you have a laptop you can bring to every STRIVE session?

Yes
No

Are you involved in any extra-curricular activities that could cause you to miss more than one session a semester?

What do you think you'll need support with this year? You may include subjects as well as skills like organization, time-management & productivity.

Is there anything you'd like to see in STRIVE this year that you felt was missing in past years?

What did you like from previous STRIVE years/sessions?

Do you have a mentor from the past (that hasn't graduated) that you would like to work with again this year? If so please provide their first & last name, email and/or phone number if you have it.

Photo and Likeness Release*

I, the student, agree
I, the parent/guardian, agree
We do not agree

By checking this box, both parent/guardian and student agree to City Academy taking pictures, audio, and video of the student while attending STRIVE. I understand that audio and/or video recordings and photographs may be made of me (the parent or guardian) and my child/ren (student/s at City Academy) and my or my child/ren’s name, likeness, image, voice, statements (in audio or print form), appearance, and biographical information (the “Images and Sounds”) during my participation one or more programs with City Academy. I grant to City Academy and their agents, licensees and assigns (collectively “Releasees”), the perpetual, royalty-free, worldwide rights to make, use, publish, perform, copy, alter, distribute, register as a copyright, and make and license derivative works from, the Images and Sounds, in any media, now known or hereafter developed, for promotional or any other lawful purpose. I also authorize the use of any printed material in connection with the Images and Sounds. I waive any right to inspect or approve the finished materials, or the promotional or other copy that may be used in connection with the Images and Sounds, or any use to which they may be applied. I release, discharge, and agree to hold harmless Releasees from any liability arising out of any use of the Images and Sounds, and from any claims sounding in defamation, right of privacy, right of publicity, misappropriation, or similar proprietary right. I have the authority to grant Releasees the rights granted herein. I have read the above Release prior to its execution and understand the contents hereof. I grant all rights above in consideration of permission to participate in one or more programs with City Academy and other good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge. I acknowledge that I will not receive any further consideration for any of the rights granted under this Release.

STRIVE Registration Form