REEA Membership Application

Radianceeea.weebly.
com
[email protected]
P: 510-375-6162
Bring this completed form to your assessment appointment
MEMBERSHIP APPLICATION
APPLICANT INFORMATION
Students Name:
Date of birth:
Age:
Phone:
City:
State:
ZIP Code:
High School:
Grade:
Facebook
Name:
Email:
Nickname:
Current address:
Allergies:
PARENT/GUARDIAN INFORMATION
Name:
(If different from student)

Address:
Phone:
Email:
City:
State:
ZIP Code:
EMERGENCY CONTACT
Name:
Address:
Phone:
City:
State:
ZIP Code:
Relationship:
ADDITIONAL AUTHORIZED PERSON FOR PICK-UP
Name:
Address:
City:
Relationship:
PARENT STATEMENT OF UNDERSTANDING
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!
!
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I understand that if my child is under the age of 18, she will not be release to any person(s) not listed on the enrollment
form.
I understand that pick-up person(s) may be asked to provide identification that he/she is who they claim to be.
I understand that my child will not be released to any person(s) who seem to be under the influence of drugs or alcohol.
I understand that I am not to leave my child at Radiance: Educate. Empower. Achieve. unless a REEA staff member or
volunteer is there to receive and supervise my child.
I understand that if my child is under the age of 18, it is my responsibility to sign my child in and out before leaving.
Sign-in/Sign-out sheets are available as you arrive at the program area.
I understand that REEA is mandated to report any suspected cases of child abuse or neglect to the appropriate authorities
for investigation.
I have read and understand the statements above regarding REEA policies and procedures
Signature of Parent/Guardian of
Participant UNDER the Age of 18:
Date:
I have read and understand the statements above regarding REEA policies and procedures
Signature of Student OVER the Age of 18:
Date:
Radianceeea.weebly.com
[email protected]
P: 510-375-6162
* Fees:
!
One-time Application Processing Fee: $25.00
!
Monthly Membership Fee: $75.00
*APPLICATOIN FEE AND 1ST MONTHS MEMBERSHIP FEE IS DUE AT TIME OF REGISTRATION,
PAYMENT OPTIONS ARE AVAILABLE FOR 2nd PAYMENT AND FORWARD
Payment Options:
OPTION 1: Pay application processing fee and annual membership fees in full at the time of registration
OPTION 2: Pay membership fees on a monthly basis
PLEASE COMPLETE PAYMENT AUTHORIZATION BELOW

CREDIT CARD AUTHORIZATION
Drafts will occur on approximately the 10th and 26th. INITIALS ______
I authorize REEA to charge my credit card for membership payments. I understand that I must provide written notice of
cancellation. If at any time there is to be a change, deletion, or cancellation of my childs enrollment, it is to be
submitted in writing to REEA two weeks prior to the date my credit card draft in order to discontinue the debit.
___________________________________
NAME AS IT APPEARS ON CARD
______________
CARD ISSUER
___________________________________
CREDIT CARD NUMBER
___________
EXP. DATE
AMEX
MC
VISA
DISCOVER
______________________________________
SIGNATURE OF CARD HOLDER
BILLING ADDRESS OF CARDHOLDER: _________________________________________________________________

CITY:________________________ STATE: ________ ZIP: ____________________
Radianceeea.weebly.com
[email protected]
P: 510-375-6162

PARTICIPANT WAIVER FORM
ACKNOWLEDGEMENT
I understand that Radiance: Educate. Empower. Achieve., LLC (REEA) and its employees, agents, counselors,
teachers, trainers, volunteers, representatives, successors and assigns assume no responsibility for loss, damage, illness or injury to
person or property that I or my minor child(ren) or ward(s), if applicable, may sustain as a result of my or their physical condition
or resulting from my or their participation in any activities, programs, events, classes, the use or non-use of any equipment, classes,
events or programs at and/or sponsored by REEA. I expressly acknowledge, on behalf of myself and my minor child(ren) and
ward(s), heirs and executors, that I voluntarily assume the sole risk for any and all dangers, illnesses and personal injuries that may
result from my or my minor child(ren)s ward(s) participation in any events/activities/programs/classes while at REEA and/or
sponsored by REEA.
I also acknowledge that REEA often uses photographs, videotapes, and tape recordings, or other similar media for
promotional purposes. I hereby consent to the use of my and/or my minor child(ren)s or ward(s) names and/or likeness(es) in
such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other
similar purposes, even if my and/or minor child(ren)s or ward(s) name(s) and/or likeness(es) are an integral part of such
photograph, videotape, tape recording or other similar media.
RELEASE
In consideration of REEA allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any
programs, events, classes, or other activities at REEA and/or sponsored by REEA, I hereby, for myself, my agents, counselors,
teachers, trainers, volunteers, representatives, successors and assigns, from and against any and all rights and participation in any
such programs, events, classes, and other activities, whether or not such loss, damage or injury results from the negligence of
REEA and its employees, agents, or representatives or from some other cause. My agreement to release REEA does not include any
loss, damage or injury that results from REEAs gross negligence or willful, wanton, or reckless misconduct.
I further waive any and all rights to inspect or approve the photography, videotape, television program, motion picture,
tape recording or other use of my and/or my child(ren)s or ward(s) name(s) and/or likeness(es), including any written article,
script, caption or other writing that may accompany such use of my and/or my minor child(ren)s or ward(s) name(s) and/or
likeness(es). I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, successors and assigns, from and
against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversation,
defamation, appropriation of likeness or any other claim based on the use of my and/or my minor child(ren) or ward(s) name(s)
and/or likeness(es) in any such materials.
IDEMNIFICATION
I hereby represent and warrant to REEA that I have the authority to execute the Participant Waiver Form on behalf of
myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any
misrepresentation of breach of the foregoing warranty by me, or in the event that I , my minor child(ren) or ward(s), or any other
person nevertheless asserts any claim against REEA arising out of my or my minor child(ren)s or ward(s) participation in any
program, event, class or other activity as set forth herein, I agree to indemnify , hold harmless and defend REEA from and against
any and all liability, claims, losses, costs, expenses or damages resulting loss damages, illness or injury results from the negligence
of REEA or from some other cause.
ACCEPTANCE
I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form.
___________________________________________________________________________________
Signature of Participant or Parent/Guardian of Participant(s) under
Date
the Age of 18
______________________________________________
______________________________________________
______________________________________________
Name(s) and Age(s) of Participant(s) under the Age of 18, if any

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Radianceeea.weebly.

Bring this completed form to your assessment appointment

(If different from student)

Bring this completed form to your assessment appointment

PLEASE COMPLETE PAYMENT AUTHORIZATION BELOW

BILLING ADDRESS OF CARDHOLDER: _________________________________________________________________

Bring this completed form to your assessment appointment

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