Apply Online.

Please fill out the following application through our website and click Submit when finished. We will process your application and e-mail/call you with further instructions to complete the application and the registration process.

Student Name:
Parent Name:
Street:
City:
State:
Zip Code:
Phone Number: - -
Gender:
School Name:
E-mail Address:
Age:
Grade:
T-Shirt Size:
Emergency Contact Name:
Emergency Contact Phone:
Emergency Contact Relationship:
Healtcare Info:
illnesses, medications, dosage/frequency etc.
Does Tour Participant Have Health Insurance:
Insurance Company:
Policy Holder Name:
Policy Number:
Group Number:
Primary Care Physician:
Physician Phone Number:

Parent/Guardian Authorization: I have read and completed the above registration form on behalf of the tour participant. The tour participant and I comply with contained information. As the parent/guardian, I hereby grant permission for the above referenced tour participant to engage in all activities associated with the Caring For Young Minds Black College Tour. I further give permission for the above registered tour participant to travel interstate as designated by the Caring For Young Minds Black College Tour organization. I also give full permission for the organization to arrange all necessary food, lodging, and transportation for registrant.

Pertinent medical information has been provided to make necessary emergency decisions should the need arise/if applicable. All tour participants are instructed to self medicate. However, in the event of an emergency, I hereby give permission to the nurse on tour, physician or medical personnel selected by the tour to secure and administer treatment, including hospitalization, for my child. In the event I cannot be reached, I give permission to the Caring For Young Minds Black College Tour to seek emergency medical treatment including administering necessary medication, ordering x-rays or routine tests. I agree to the release of any records necessary for emergency medical decisions and insurance purposes.

I hereby hold harmless, indemnify and defend Caring for Young Minds Black College Tour, Inc., its officers, volunteers, and all affiliates of the tour for and from any and all liability, claims, losses, injuries, expenses, fee and/or damages arising out of any injury, illness or death to my child or property damage during my child’s participation with the tour. I further release and will not hold liable Caring For Young Minds Black College Tour and all affiliates for any injury, death, damage and/or loss to my child, and/or anyone claiming on my child's behalf, and I further agree to hold harmless, indemnify and defend.

A $150.00 non-refundable deposit is required to reserve your seat on the tour with the balance to follow. All payments submitted are non-refundable and non-transferable. In the event the referenced participant is unable to attend the tour, monies received will be donated to the tour. Make checks payable to Caring for Young Minds, Inc., mail to 11 North Stead Court, Catonsville, MD 21228.

Said schedule of itinerary is subject to change at any time without notification. Decisions are made on behalf of the best interest of the participants. Inclement weather and safety issues may cause changes in the Travel Itinerary and recreational activities without notice. Alternate arrangements for said changes are at the sole discretion and of the Tour Coordinators. Contact 410-935-7017 or caringforyoung@aol.com

Electronic Signature
by clicking this box, you agree to all terms stated previously by the Caring For Young Minds, organization and this further serves as a authorized signature.

Type Name:

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