LPEP Rally Registration
1.
Parent Name
2.
Phone Number
3.
Email
4.
Child's Name and Preferred Pronoun
5.
Ethnicity (Optional)
6.
Does your family qualify for free or reduced lunch?
Yes
No
7.
Emergency Contact Name and Phone Number
8.
Food allergies?
9.
Which LPEP Rally or Rallies are you registering for?
February 21, 2022
April 25, 2022
10.
I give my child/children permission to participate in the LPEP Rally event(s) and I hereby release and forever discharge and hold harmless the Lafayette Empowerment Center and its staff members, volunteers, board members, and community partners from any and all liability, claims, and demands of any nature, which arise or may hereafter arise from the below names minor child's participation in this program. I also give the Lafayette Empowerment Center permission to photograph my child(ren) for outreach and reporting purposes. By submitting this form, I agree to the above statement.
Guardian Name:
Current Progress,
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