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Home
About
Job Opportunity
Volunteer Application
Our Programs
Eryn Pink Girl Empowerment
Men of ICE Middle School Leadership Program
EPIC High School Young Professional Program
The Baller’s Conference
ICE Mentors School Program
POWER: The State of Man
EPIC Summer Program
Contact
Shop
#BETTER TOGETHER | Donations and Sponsorships
24 -25 Men of ICE Leadership Registration
2024-25 Men of ICE Program
Student First Name
*
Student Last Name
*
Student Grade
*
6th
7th
8th
Student Grade
Student Date of Birth
*
Student Gender
*
Male
Female
Other
Student Gender
Student Phone Number
*
Student Email
*
Student Address
*
Student School
*
List allergies, if any:
Parent Information
Parent First Name
*
Parent Last Name
*
Parent Email
*
Parent Phone
*
Parent Address
*
Parent Address
Parent Address
Parent Address
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Zip/Postal
Additional Emergency Contact Info
Permission to Participate
REQUIRED PERMISSION: Permission to Participate: I hereby give permission for my child to participate in this program. MY CHILD IS AVAILABLE TO ATTEND EACH DATE. Medical Authorization: I authorize the staff of the summer program to seek medical treatment for my child in case of an emergency, and I agree to be financially responsible for any medical expenses incurred. Transportation Authorization: I give permission for my child to be transported to and from program activities or field trips during the summer program. Photo/Video Release: I consent to the use of photographs or videos of my child taken during the summer program for promotional or educational purposes related to the program. Emergency Contact Information: I confirm that the emergency contact information provided is accurate, and I authorize program staff to contact the listed individual in case of an emergency involving my child.
*
Yes
No
Payment Information
Payment
*
Program Cost
*
$
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