The RESET Registration & Waiver Form Please complete all sections to register for The RESET program and review the waiver. Participant Information Participant Full Name* First NameMiddle NameLast Name Age* Date of Birth* -Month -DayYearDate Gender* MaleFemale School or Organization Name* Grade Level* Please Select Pre-K Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Other Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Email Address* example@example.com Home Address* Street Address Street Address Line 2CityState / ProvincePostal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Emergency Contact Name* First NameMiddle NameLast Name Emergency Contact Relationship* Emergency Contact Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Parent/Guardian Information Parent/Guardian Full Name* First NameMiddle NameLast Name Parent/Guardian Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Parent/Guardian Email Address* example@example.com Parent/Guardian Signature* Program Interest & Support Needs What types of support or program interests are you looking for?* Emotional regulation supportAnger processingOne-on-one mentorshipGroup mentorshipTrauma-informed supportConflict resolutionConfidence buildingLeadership developmentBoxing-based fitnessCommunity engagementSQ101 deeper supportOther What challenges, goals, or support would you like us to know about?* Medical & Safety Allergies* Medical conditions* Current medications* Mental health concerns or triggers we should be aware of* Emergency medical authorization* I authorize emergency medical treatment if needed Liability Waiver & Release Participant Signature* Parent/Guardian Signature (if under 18) Date* -Month -DayYearDate Communication Opt-Ins Communication preferences* Receive program updates and important notifications by text messageReceive emails regarding programming, events, mentorship opportunities, and community initiativesI understand I can opt out at any time Text message consent Email consent SubmitSubmit Should be Empty:
