Independent Study Program Registration - Crossover Mission

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Our Programs
Our Impact
Get Involved
Capital Campaign
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- Naming Opportunities
Volunteer

Independent Study Program RegistrationDaniel Torres2025-11-04T05:11:02-05:00

Independent Study Program Registration

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We welcome you to the Crossover Mission Independent Study Program Registration Application.
📝 Registration Instructions

Welcome! Please follow the steps below to complete your registration with Crossover Mission:
1. Complete the Form: The form must be filled out completely by an authorized parent or guardian.
2. Fill Out All 5 Steps: Make sure you complete all five sections of the form before moving forward.
3. Sign Policy Documents: After completing the form, you’ll be asked to digitally sign all required Crossover Mission policy documents.
4. Upload Required Documents:
  - 📄 Student Birth Certificate
  - 🏥 Student Sports Physical
  - 🪪 Parent/Guardian Driver’s License or Government-Issued ID
  - 💳 Health Care Card (optional)
5. Make Payment: After uploading your documents, you’ll be directed to the payment page.
  💳 Be ready to pay with a debit or credit card.
  ⚠️ Incomplete payment may delay your registration.

I would like to register my student for:*
- Independent Study Program
Are you a new or returning student?*
- New Student
- Returning Student
Independent Study Program 2025-26 Registration and Release Form
Date*
MM slash DD slash YYYY
Student Name*
First Last
Student Nickname
Birth Date*
MM slash DD slash YYYY
Age*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Height*
Weight*
Gender*
- Male
- Female
Student Cell
Student Email Address
School Name*
School Dismissal Time*
Grade*
Student ID*
Student - T Shirt size*
Uniform size
Student - Shorts size*
Uniform size
Student Desired Level of Basketball Training*
- Competitive Basketball
- Recreational Basketball
Previous Basketball Experience (check all that apply)*
- No previous organized basketball experience
- Recreation basketball participation
- School basketball team participation
- Travel basketball team participation
Parent/Guardian Information
This field is hidden when viewing the form
Date
MM slash DD slash YYYY
Parent/Guardian*
First Last
Parent/Guardian Nickname
Relationship to the Student*
Parent Cell Phone*
Please use your preferred phone number where you can be reached most often
Parent Email*
Email will be the primary form of communication for schedules and events from Crossover Mission. If your email changes, please notify us immediately.
Parent/Guardian Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Occupation*
Employer*
How did you hear about Crossover?*
- From a friend
- Online
- From a community event
- From Crossover staff
- Other
Tell us more about how you got interested in Crossover
Does the student have a second parent or guardian?*
- Yes
- No
Parent/Guardian #2
Parent/Guardian #2 (if applicable)
First Last
Parent/Guardian Nickname
Relationship to the Student
Parent Cell Phone
Please use your preferred phone number where you can be reached most often
Parent Email
Email will be the primary form of communication for schedules and events from Crossover Mission. If your email changes, please notify us immediately.
Parent/Guardian Address (if different from above)
Street Address City State / Province / Region ZIP / Postal Code Country
Occupation
Employer

Student Demographics
This information is required for tracking and grant funding purposes. All information will be kept confidential and will not be used in any identifying way to outside organizations.
Race*
- African American/Black
- Caucasian/White
- Hispanic
- Asian
- Multi Racial
- Other
Location of Primary Residence*
Habitat Home Owner
- Habitat Home Owner
Total Number in Household*
Number of children in household*
Is your student currently involved in any other programs in the community? If so, please list*
- Yes
- No
Please list*
Family Setting*
Check all that apply
- Both Parents
- Mother Only
- Father Only
- Grandparent(s)
- Guardian(s)
- Parent/Step Parent
- Foster Care
- Group Home
Household Income*
Have you been homeless in the last year*
- Yes
- No
Has one or both parents been incarcerated in the last 15 years?
- Yes
- No
- Prefer not to answer
We never share personal information or demographic information, only on average to funders. We will not limit your entry or change the fee based on this information.

Student Medical Information
Medical Concerns?*
Please include allergies (especially to medications)
- Yes
- No
Please explain the student's medical concerns
Medical Information/Allergies/Special Needs*
Taking Medications?*
- Yes
- No
Please list the medications that your student is currently taking
This information will be used only to communicate with emergency responders in the case of an emergency.
EpiPen*
- Yes
- No
Special Needs?*
- Yes
- No
Please explain any special needs that your student may have
Are there accommodations that can be made by Crossover Mission to help your student participate fully?
Type of Health Insurance*
Emergency Contact Information
Name (other than primary parent(s))*
First Last
Relationship*
Emergency Contact Cell Phone*
Emergency Contact Work Phone*

Release of Liability
Release of General Liability I agree to accept any liability for personal injury arising out of my student'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. Release of Liability I am the parent/guardian of of the student listed above who is participating in the basketball training and academic mentoring program offered by Crossover Mission, Inc. Vero Beach, FL, and held at the Crossover Center, School District of Indian River County and other contracted facilities. I do understand that participation in this sporting activity is potentially dangerous and serious injury may occur. I hereby release any claim of any nature which I or my minor student might have against Crossover Mission, Inc. its officers, agents, employees, volunteers and the School District of Indian River County from any and all liability for any injury incurred during this program or incurred while being transported by automobile by a Crossover Mission staff member, tutor, coach, mentor or volunteer. I attest and verify that I have full knowledge and understanding of any and all risks involved in such participation, and that I will, on behalf of the named student, assume full responsibility for such risks and pay any and all medical, emergency, and other costs.
I have read, acknowledged, and understand the releases of liability above in totality and agree*
- Yes
- No
Crossover offers support for registered Crossover students/parents with Individual Education Plans (IEPs) or 504 Plans. Does your student have an IEP or 504 Plan*
Photo Release: I hereby authorize and consent to the use of his/her visual image by Crossover Mission, Inc. for marketing and reporting 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.*
- Yes
- No
Communication Authorization & Release
I hereby authorize the staff of Crossover Mission, Inc. to communicate with my student for appropriate purposes, using, but not limited to, email, text, cell phone, and other social media.
Communication Authorization and Release*
- Yes
- No
Tutoring Registration & Release
As parent/guardian, I understand that I will be part of the goal setting process for my student, and I will allow my student's school to release relevant educational information regarding my student to the tutors/mentors of Crossover Mission, Inc. for academic assistance. I give authorization for my student to be transported by authorized members of the Crossover Mission, Inc. organization for academic support and training purposes. I allow Crossover Mission access to school academic portals. Included in that is the Indian River County School District FOCUS portal, St. Edward's Student Academic Portal, Florida Virtual Portal, Homeschool Academic Portals and plans, and any other programs aimed at improving academic performance within the school district. These online tools provide updates on my student'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 separate release forms. All information is kept strictly confidential by Crossover Management.
Tutoring Registration and Release*
- Yes
- No
Emergency Authorization and Health Insurance
I, the undersigned, as parent/guardian of the named student, 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. All information is kept strictly confidential by Crossover Management.
Emergency Authorization and Health Insurance*
- Yes
- No
Parent Support Requirement
All parent/guardians of Crossover participants are required to volunteer for one event each school year. Please select the volunteer activities that interest you.
Select all that apply*
- Select All
- Work the Greeting/Admissions Table
- Help Set up/Clean up Events
- Chaperone Outings/Events
- Help Run Games and Tournaments
Electronic Parent/Guardian Signature*
I agree to all the terms stated above for my student'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 student to participate in Crossover Mission.
Fees
Please contact the Crossover Mission office to determine your payment.
Fees*
- I am prepared to pay the fee per student Crossover Registration fee (basketball uniform is included)
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4425 US Highway 1
Vero Beach, FL 32967
772.257.5400

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Crossover Mission helps the kids who need us most to become successful adults through year-round basketball training and one-to-one academic support and life skills mentoring.

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