Event Registration

First Name: Last Name: Email: Cell Phone: Birth Date: / / Grade: 6 7 8 9 10 11 12 Gender: Male Female Non-binary Prefer not to say Ethnicity: Hispanic/Latino Not Hispanic/Latino How did you hear about the Torch Training? Word of Mouth Website Newsletter School Administrator/Teacher Torch Staff Other School: Areas of Interest (Select all that apply) Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix First Name: Last Name: Email: Cell Phone: Relationship to Student: Is the Parent/Guardian's Home Address the same as the Student's? (If not, please proceed with the questions below) Yes No Is the Parent/Guardian the emergency contact? (If no, please proceed with the questions below) Yes No First Name: Last Name: Email: Cell Phone: Relationship to Student: Does your child have any chronic health problems or physical disabilities? Yes No If yes, please describe Has your child had psychological counseling in the last 12 months? Yes No If yes, please describe Does your child take medication(s) that we should be aware of? Yes No If yes, please describe Does your child have any conditions, learning disabilities, allergies, special needs, or anything else that we should be aware of? Yes No If yes, please describe Has your child been hospitalized for an emotional problem within the last six months? (If yes, your child is not eligible to participate) Yes No If your child is female, is your child pregnant? If yes, your child is not eligible to participate in the Torch Training at this time. Yes No Anything additional we should know about the student? I have read and I understand the description above in regard to the Torch Trainings. Yes No I want to be contacted Please provide your electronic signature below indicating that you understand and agree to this Parent/Guardian Consent and Release for The Torch Foundation in its entirety. I accept that I must surrender my phone during the Torch Foundation workshop. Yes I understand that this is a 2 (two) day workshop and 4 (four) week coaching and that my full participation is important Yes Please provide your electronic signature below indicating that you understand and will abide with The Torch Foundation protocol in its entirety.