Parent Name *

First Name

Last Name

Phone *

(###)

###

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Student Name *

First Name

Last Name

Student DOB *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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Media Waiver *

By checking the box below, each participant consents to the use of interview, quotes, photographs, movies, or videotapes of his/her self by The Prep Year and the use, or reuse of said products for purposes including print, internet, and all other forms of media. The undersigned agrees to release The Prep Year and all its agents and employees from all claims, demands, and liabilities in connection with the above. By agreeing on this form, the undersigned hereby acknowledges that he/she has read the above carefully, and agrees to comply with it.

I Agree