The HBCU Kid 2027 College Tour Registration Form The HBCU Kid 2027 Spring Break Tour - Philander Smith, University of Arkansas at Pine Bluff, Jackson State University, Mississippi Valley State Univer "*" indicates required fields Step 1 of 4 25% **Important Information** No refunds are issued four weeks before the departure date. STUDENT/PARENT INFORMATIONPlease indicate below whether you are filling out this for the student or as a parent going on the trip. If you are a parent that plans to go on the trip with your child, please submit another application and fill it out as the parent. Student/Parent* Parent Student Gender* Male Female Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Grade Level*6789101112Shirt Size*Youth SmallYouth MediumYouth LargeYouth XLSmallMediumLargeX-Large2X-Large3X-Large PARENT/GUARDIAN #1 INFORMATIONName* First Last Phone*Email* PARENT/GUARDIAN #2 INFORMATIONName First Last PhoneEmail Parental Consent I agree to the parental consent policy.I certify that I have read and reviewed the following with my child: conduct agreement, medical release form, what to bring/what not to bring, and permission to use image. I give my child permission to attend the above named event hosted by The HBCU Kid™. I will hold neither The HBCU Kid™and its officers responsible for any actions, mishaps, or loss (including death) that may occur during this event. Furthermore, I understand that if my child is involved in any illegal actions (including, but not limited to possession of illegal substances, alcohol, cigarettes, tobacco, weapons, weapon look-alikes, or fake identification) or inappropriate conduct (including, but not limited to fighting, harassment, sexual misconduct, profanity, theft, failure to comply with curfew, or disrespect toward chaperones or tour guides), I will be contacted immediately and in extreme circumstances, my child may be dismissed from the tour and I may be required to travel at my own expense to retrieve my child. I understand that any and all payments will not be refunded. HEALTH INFORMATION PLEASE CHECK HERE IF THE CHILD IS NOT COVERED BY HEALTH INSURANCE.Name of Health Insurance Name of Policy Holder Group Name Policy Number Emergency Contact Number*Emergency Contact NumberEmergency Contact Number Does your child have any illness, health conditions, mobility limitations, or communicable disease that we should be aware of?* Yes No If so, please list:Does your child have an allergy to any foods or medications?* Yes No If so, please list:Is your child required by a medical doctor to take any medications?* Yes No If so, please list:Does your student have special dietary needs?* Yes No If so, please list:CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
