I affirm that I am the parent/guardian of the student listed above and do reside at the above address. I understand that my student will be participating in the basketball training and academic mentoring program offered by Crossover Mission, Inc., Vero Beach, FL, and held at the Crossover Center, Gifford Youth Achievement Center, School District of IRC and any other contracted facility. I do understand that participation in this sporting activity is potentially dangerous and that physical injury, including serious injury may occur. I give permission for my child/ward to be transported via automobile by a staff member of Crossover Mission, Inc. and hereby waive my rights to all claims for injuries my minor child/ward might sustain while being transported via automobile by a Crossover Mission staff member, tutor, coach or mentor. I agree to accept any liability for personal injury arising out of my child’s participation in athletic, academic and mentoring activities of Crossover Mission. I understand and acknowledge that Crossover Mission, Inc. is a community supported, 501(c)(3) organization, and I agree it is not a commercial activity. I hereby release any claim of any nature which I or my minor child might have against Crossover Mission, Inc., its officers, agents and employees or the Gifford Youth Achievement Center and the School District of IRC from any liability for any injury incurred during this program or incurred while being transported by automobile by a Crossover Mission staff member, tutor, coach or mentor. I attest and verify that I have full knowledge of any and all risks involved in such participation, and that I will, on behalf of the named child, assume full responsibility for such risks and pay any and all medical, emergency, and other costs.

I hereby authorize and consent to the use of his/her visual image by Crossover Mission, Inc. for appropriate purposes, including but not limited to: still photography, videotape, electronic and print publications, websites and social media. I give this consent with no claim for payment.

I hereby authorize the staff of Crossover Mission, Inc. to communicate with my child for appropriate purposes, using, but not limited to, email, text, cell phone, and other social media.

As parent/guardian, I understand that I will be part of the goal setting process for my child, and I will allow my child’s school to release relevant educational information regarding my child to the tutors/mentors of Crossover Mission, Inc. for academic assistance. I give authorization for my child to be transported by authorized members of the Crossover Mission, Inc. organization for academic support and training purposes. I allow Crossover Mission access to the Indian River County School District FOCUS portal and any other programs aimed at improving academic performance within the school district. These online tools provide updates on my child’s performance and are necessary for effective and meaningful, weekly academic mentoring. In order to provide access to the electronic portals/gradebooks by the Crossover tutors/mentors, I provide Crossover Mission with the SDIRC Release Form. All information is kept strictly confidential by Crossover Management.

I, the undersigned, as parent/guardian of the named child, hereby authorize the staff of Crossover Mission, Inc. and its sponsors and vehicle drivers as my agents, to consent to medical, surgical, dental examination or treatment, and/or care at any hospital or by licensed medical personnel in the event of emergency.

I agree to all the terms stated above for my child’s participation in the Crossover Mission, Inc. athletic and academic program. This may also include field trips and out of town events. I attest to the accuracy of the provided information and understand that I must complete this application in its entirety for my child to participate in Crossover Mission.

Total 2019 AAU Fees: $800
Fees may be paid in 3 installments
Initial $300 Payment Due: March 22, 2019
2nd $300 Payment Due: April 26, 2019
Final $200 Payment Due: May 24, 2019