Community Service Hours (9-14-24)

Saturday, Sept. 14 - Beyond Pain Program @ Miller Library

This registration MUST be completed by a parent/guardian for anyone under 18 years of age.

For middle or high school students to receive community service hours, 1) student must be a Howard County student, 2) student must attend the entire event and fully participate, and 3) student must sign in/out at the event. Thank you.

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* 1. Student's first name

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* 2. Student's last name

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* 3. Parent/Guardian's full name (Again, this registration MUST be completed by parent/guardian)

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* 4. Will you or another adult be attending with your student?

No, my student will attend alone

Yes, I will attend with my student

Yes, another adult will attend and here is their name:

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* 5. Email address of parent/guardian

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* 6. Re-enter parent/guardian email address

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* 7. Phone number of parent/guardian

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* 8. (optional) If different, phone number of student

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* 9. (optional) Email to contact student

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* 10. If student is in high school, which school do they attend? If in middle school, please skip to the next question.

Atholton HS

Centennial HS

Glenelg HS

Glenelg Country School

Guilford Park HS

Hammond HS

Howard HS

Long Reach HS

Marriotts Ridge HS

Mt. Hebron HS

Oakland Mills HS

Reservoir HS

River Hill HS

Wilde Lake HS

Homeschool

Other (please specify)

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* 11. If student is in middle school, which school do they attend?

Bonnie Branch MS

Burleigh Manor MS

Clarksville MS

Dunloggin MS

Elkridge Landing MS

Ellicott Mills MS

Folly Quarter MS

Glenelg Country School

Glenwood MS

Hammond MS

Harper's Choice MS

Lake Elkhorn MS

Lime Kiln MS

Mayfield Woods MS

Mount View MS

Murray Hill MS

Oakland Mills MS

Patapsco MS

Patuxent Valley MS

Thomas Viaduct MS

Wilde Lake MS

Homeschool

Other (please specify)

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* 12. Grade?

8th

9th

10th

11th

12th

Other (please specify)

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* 13. THIS EVENT IS OPEN TO THE PUBLIC. PHOTOS, ETC., MAY BE RELEASED.

Participation Waiver for Parents/Guardians

By submitting this registration and as the parent and/or legal guardian of this youth/student, I agree to this waiver(s):

I have read this waiver and knowing the facts, I, for myself and anyone entitled to act on my behalf, waive and release HC DrugFree and its employees, directors, officers, partners, agents, and sponsors from and against all claims, demands or causes of actions for accidents, personal injury, bodily injury, death, property damage or other injury or loss or damage of any kind, occurring from any cause arising from or related to or in connection with named participant’s involvement in the event named above.

Further, I grant permission to all of the foregoing to use named participant’s photographs, audio and audio visual recordings or any other record of this event for any legitimate purpose.

I understand that it is my responsibility to IMMEDIATELY report any injury or concerns to HC DrugFree’s Staff or Board Member present at this event AND to notify Staff at the Library.

Yes, I agree to the above

Community Service Hours (9-14-24)

Saturday, Sept. 14 - Beyond Pain Program @ Miller Library

Question Title

* 1. Student's first name

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* 2. Student's last name

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* 3. Parent/Guardian's full name (Again, this registration MUST be completed by parent/guardian)

Question Title

* 4. Will you or another adult be attending with your student?

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* 5. Email address of parent/guardian

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* 6. Re-enter parent/guardian email address

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* 7. Phone number of parent/guardian

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* 8. (optional) If different, phone number of student

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* 9. (optional) Email to contact student

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* 10. If student is in high school, which school do they attend? If in middle school, please skip to the next question.

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* 11. If student is in middle school, which school do they attend?

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* 12. Grade?

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* 14. Thank you for completing this registration.