Youth Initiative Mentoring Academies (YIMA) - Registration Form
Last Name: First Name: Middle Init.: Phone: Email:
Address: City: State: Zip:
Age: Date of Birth: Goes to School Where?
Driver’s License No.: Collected later Social Security No.: Collected later
Place of Employment: Business Phone:
Additional family members taking lessons:
Referred by:
PARENT’S INFORMATION (if under 18)
Father’s Last Name: First: Middle Init: Age:
Mother’s Last Name: First: Middle Init: Age:
Indicate which parent: Father: Mother:
Address: City: State: Zip:
Phone: Drivers License No.: Collected later Social Security No.: Collected later
Place of Employment: Business Phone:

FIELD TRIPS
Field trips are an important part of the Youth Initiative Aviation Academy. Your signature authorizes your son/daughter/ward to attend field trips that are developed as part of this class. We understand that the necessary arrangements/plans/precautions will be taken for the care and supervision of the student during this trip.
I/We authorize to participate in Youth Initiative Aviation Academy field trips.
Registrant’s Signature (or Parent/Guardian if under 18): Date:
RELEASE
I hereby grant Youth Initiative Mentoring Academies/Youth Initiative Aviation Academy and its agents and assigns the right and per-mission to use of my sons daughter’s name and reproduction of physical likeness for the purpose of publicizing the program through the pamphlets, video, newspaper, periodicals, etc.
Registrant’s Signature (or Parent/Guardian if under 18): Date:
 

You acknowledge that instruction and training in the flight academy is physically strenuous and involves the risk of injury. You rep-resent that you are physically fit to undertake our training activities. You agree that all activities and the use of our facilities are at your own risk and that we, our instructors and our other students will not be liable for any claims, demands, injuries, damages, or actions resulting from your use of our services and facilities. You also agree not to sue us, our instructors and other employees for any injury or loss resulting from the use of our services and facilities.


There is no health insurance or medical coverage provided by this program. The signing of this form acknowledges that the students parent/guardian accepts responsibility for payment of any medical treatment which may be required while they are in the program.
Registrant’s Signature (or Parent/Guardian if under 18): Date:
Signature of School Counselor (if enrolled in K-12 school): Not Applicable Date: NA