Health and Wellness Session

Jared's Heart Of Success, Inc.

Program Location

2165 West Park Ct, Suite F

Stone Mountain, GA 30887
http://www.jaredsheartofsuccess.com

Participant Information

First Name

Last Name

Gender

Birth Date +

Grade

Please list below *

Elementary School-youth

Middle School-youth

High School-young adult

Adult

Guardian / Adult Primary Contact

Relationship to Participant: *

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone

Alternate Phone

Email Address *

By signing below you are giving permission for youth/young adult to attend, permission for photos, pictures or videos of your child/children to be taken and use by the organization for promotional use. Also that your child/children are able to participate in excercise actitivities and you will not hold the organization or its representatives responsible for injury of any kind. We advise that you consult with your physician prior to performing any exercises or physical activity vigorous or non-vigorous. *

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