Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Last Tetanus Shot

Please consult with your physician or medical department if you are not up do date in order to decrease risk.

MM

DD

YYYY

Confidentiality Agreement *

I understand that all information (written and verbal) about participant at this center is confidential and will not be shared with anyone without expressed written consent of the participant and his/her parent/guardian in the case of a minor.

I agree

I do not agree

Photo Release *

I consent to and authorize the use and reproduction by Justin's Place of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

I do consent

I do not consent

By typing my name below I understand the information provided above is accurate to the best of my knowledge. I know of no reason why I should not participate in this center's program. *

First Name

Last Name

Todays Date *

MM

DD

YYYY

Please check the boxes to verify understanding. *

I understand that Justin's Place reserves the right to accept and decline applicant.s

I understand that this program is on a volunteer basis and is unpaid.

I understand I need to be available for the two clinics in August and 2 hours per week for sessions during September to November.

I understand this program cost is $800 and will be waived if I agree to teach for the 2026 programming year at 2 hours per week.