FIERCE TEEN APPLICATION

FIERCE TEEN APPLICATION

GUARDIAN INFORMATION
Who is completing this Application?*

MotherFatherLegal GuardianFamily MemberStep-Mother/Step-FatherOther
Full Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number*

Area CodePhone Number
Work Number (Emergency Only)

Area CodePhone Number
Occupation:
Emergency Contact:*
Emergency Contact Relationship to Teen:*
Other 'Please Specifiy'
Emergency Contact Phone Number*

Area CodePhone Number

DISCLAIMER & SIGNATURE
Disclaimer
The information entered above is accurate and detailed to the best of my knowledge. All information obtained by FCG is confidential and only used for the purpose of mentee informational purposes. This program is designed for personal and professional growth, and as such, boundaries need to be adhered to. This will ensure the integrity of the mentoring program. It is not acceptable to share proprietary or sensitive information at any time. FCG will not assume any legal liability issues or legal proceedings that arise from this program. The participant(s) will hold FCG harmless from any damages that occur. The participant acknowledges that FCG and their directors, officers, representatives and agents are NOT responsible for errors, omissions, acts or failures to act on any part of conducting activities on behalf of FCG. Anyone participating in the program does so voluntarily, and should rely on their own independent judgment, in determining the exercise of reasonable care in any given circumstance. I have read and understood the guidelines for the FCG and agree to follow these guidelines.
Do you Accept Disclaimer?:*

Yes
COVID Waiver
I am fully and personally responsible for my teens safety and actions while and during participation and I recognize that I may in any case be at risk of contracting COVID-19. With full knowledge of the risks involved, I hereby release, waive, discharge the Fiercely changing the Game Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me or my teen related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19. I agree to indemnify, defend, and hold harmless Fiercely Changing the Game Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.
Do you Accept COVID Waiver?*

Yes
Signature*
Enter the message as it's shown*
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