Programs Application Apply to Join J.E.S.S.I.C.A. Programs Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.SECTION 1: PARTICIPANT INFORMATIONProgram Name: *Rise & Become - 12-Step Journey ProgramPen to Power - 10-Week Author’s MasterclassR.E.P.S. - Vocational Training ProgramCEO in the Making - Entrepreneurial Mastery CourseLeadHERship AcademyRise Into Your Power Empowerment RetreatName *FirstLastDate of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age at the time of application: *Grade (Fall): *School: *Participant Email: *Participant Phone: *Home Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhy do you want to participate in this program? Please describe what you hope to gain or overcome. *Demographic Information (Optional):BlackHispanicWhiteAsianOtherSECTION 2: PARENT / GUARDIAN INFORMATION INFORMATION which Birth: Parent/Guardian #1 Name *Parent/Guardian #2 Name *Parent/Guardian #1 Relationship: *Parent/Guardian #2 Relationship: *Parent/Guardian #1 Phone *Parent/Guardian #2 Phone *Parent/Guardian #1 Email *Parent/Guardian #2 Email *SECTION 3: HEALTH HISTORYAny current/chronic illnesses? *YesNoAsthma/Wheezing? *YesNoDiabetes? *YesNoSeizures/Fainting spells? *YesNoHeadaches/Migraines? *YesNoBack/Joint problems? *YesNoAllergies (Food/Drug/Environmental)? *YesNoMental/Emotional Health concerns (ADD/ADHD, Anxiety, etc.)? *YesNoIf Yes, please list: *If Yes, has professional help been sought in the last 12 months? *YesNoInsurance Carrier: *Does the participant have any physical, mental, or medical condition which might affect involvement? If YES, please describe how we can help enhance their participation: *Policy Number: *SECTION 4: CONSENT & RELEASESPlease read carefully. Initials are required for each section.A. Medical Treatment Authorization *I give permission to the licensed medical professional selected by J.E.S.S.I.C.A. Cares staff to order x-rays, routine tests, and treatment for the applicant in emergency situations. If I cannot be reached, I give permission to hospitalize and secure proper treatment. I understand health info will be shared with staff on a "need to know" basis. Parent Initials Above.B. Transportation Release *I permit my daughter/charge to be transported by J.E.S.S.I.C.A. Cares staff/volunteers to and from program facilities (including 41 Mountain Blvd, Warren, NJ and Hayes West Rec Center, Newark, NJ). I agree to notify staff if my child will not be attending. I release J.E.S.S.I.C.A. Cares from liability arising from this transportation. Parent Initials Above.C. Photo & Video Release *I grant J.E.S.S.I.C.A. Cares full permission to photograph or video the applicant and use these images in publications, web media, and promotions without payment. All footage shall be the sole property of J.E.S.S.I.C.A. Cares. Parent Initials Above.D. Program Permission & Liability Waiver *I certify that the applicant has my permission to participate in J.E.S.S.I.C.A. Cares programs. I understand that the information provided is accurate. I hereby release and waive liability against J.E.S.S.I.C.A. Cares, its officers, and agents for any injuries or illness connected with program participation. Parent Initials Above.SECTION 5: SIGNATURESApplicant Signature: (copy) *Type Full Legal NameParent/Guardian Signature: *Type Full Legal NameDate of Application *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of ApplicationMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit Programs Application
