Programs Registration

Please complete this form if you are interested in registering for one of Pathway's programs.

First Name

Phone

Last Name

Street Address

Street Address Line 2

City

State

Zip Code

Date of Birth

Participant Age

Please list any allergies, medications, etc

Waiver & Consent Agreement:

RELEASE, WAIVER OF LIABILITY AND INDEMNIFICATION General Consent: By checking the radio button below, I hereby agree to release and hold harmless Pathway to the Future Learning Center, Inc. DBA Pathway Resource Center, Inc. and its affiliates. MEDIA RELEASE I grant to Pathway Resource Center, Inc. the exclusive right to use photograph/video or film likeness in media and promotional materials.

Yes, I have read the above waiver

If Participant is an Adult:

Household Income ($)

Participant Signature

Date

If Participant is a Youth (please fill out form fields below if you are a parent/guardian of participant):

Full Name of Parent/Guardian

Graduation Year

Parent/Guardian Phone Number

Parent/Guardian Signature

Date

Program Selection:

Thanks for registering!