Hicks Prep Club Application

Student Info

Name *

First Last

Gender

Date of Birth *

Age

Phone

Email *

School Name

School Grade

Student ID Number

Expected Graduation Year *

List Extra Curricular Activities:

Parent Info

Parent/Gardian(s) Name

First Last

Parent/Gardian(s) Name

First Last

If Guardian - Relationship to Student

Parent/Guardian Cell Number *

Parent/Guardian Email *

I reside in (please check one)

HabiJax Home
Jacksonville Housing Authority
Section 8 Housing
Other

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does your student have transportation to and from meetings and special events? *

yes
no

Which site(s) will your student be attending? *

HabiJax (Springfield/Downtown)
Southwind Villas (Regency/Arlington)
Victory Pointe (Westside)
Virtual (Online)

How did you hear about the Prep Club?

Hicks Prep Club Agreements

I accept

ACTION REQUIRED: As a Hicks Prep Club Member I agree to do the following: 1. Provide a copy of my report card each semester to the Hicks Prep Club. 2. Attend monthly meetings as scheduled. If more than 5 consecutive absentees, I agree for Hicks Staff to follow up and review status. 3. Remain drug and alcohol free and commit to signing a contract stating such. 4. Obtain written consent from a guardian for necessary forms. 5. Provide all information required in the Application. 6. Attend an Orientation prior to beginning the program. 7. Participate in activities coordinated with UNF as it relates to the Hicks Scholarship.*

ACTION REQUIRED: RELEASE, WAIVER OF LIABILITY, AND COVENANT NOT TO SUE (READ CAREFULLY BEFORE SIGNING) The undersigned hereby acknowledges that participation in activities involves an inherent risk of physical injury and assumes all such risks. The undersigned hereby agrees that for the sole consideration of Hicks Prep Club allowing the undersigned to participate in voluntary programs or activities in connection there with, and making available to the undersigned for his/her use while participating in such programs or activities, certain equipment, facilities, grounds, or personnel of the Club, the undersigned participant does hereby waive liability, release and forever discharge Hicks Prep Club, its members individually, its officers, agents, or employees from any and all demands, rights, and causes of action of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, including death, resulting from my voluntary participation in or in any way connected with such programs and activities. I further covenant and agree that for the sole consideration stated above I will not sue Hicks Prep Club, its members individually, its officers, agents, or employees for any claim for damages arising or growing out of my voluntary participation in recreational programs or athletic activities. I understand that the acceptance of this Release, Waiver of Liability, and Covenant Not to Sue Hicks Prep Club or any agent or employee thereof, shall not constitute a waiver, in whole or impart, of sovereign or official immunity by its members, officers, agents, and employees. This Release, Waiver of Liability and Covenant Not to Sue shall remain in effect for as long as I am a participant in the program or activities offered by the club. Further, I understand that, if I am an employee or student at the Institution, this Release, Waiver of Liability, and Covenant Not to Sue shall be effective during the entire period of my enrollment or employment at the Institution. I certify that I am years of age and suffering under no legal disabilities and that I have read the above carefully before signing.*

I accept

ACTION REQUIRED: RELEASE, WAIVER OF LIABILITY, AND COVENANT NOT TO SUE (READ CAREFULLY BEFORE SIGNING) The undersigned hereby acknowledges that participation in activities involves an inherent risk of physical injury and assumes all such risks. The undersigned hereby agrees that for the sole consideration of Hicks Prep Club allowing the undersigned to participate in voluntary programs or activities in connection there with, and making available to the undersigned for his/her use while participating in such programs or activities, certain equipment, facilities, grounds, or personnel of the Club, the undersigned participant does hereby waive liability, release and forever discharge Hicks Prep Club, its members individually, its officers, agents, or employees from any and all demands, rights, and causes of action of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, including death, resulting from my voluntary participation in or in any way connected with such programs and activities. I further covenant and agree that for the sole consideration stated above I will not sue Hicks Prep Club, its members individually, its officers, agents, or employees for any claim for damages arising or growing out of my voluntary participation in recreational programs or athletic activities. I understand that the acceptance of this Release, Waiver of Liability, and Covenant Not to Sue Hicks Prep Club or any agent or employee thereof, shall not constitute a waiver, in whole or impart, of sovereign or official immunity by its members, officers, agents, and employees. This Release, Waiver of Liability and Covenant Not to Sue shall remain in effect for as long as I am a participant in the program or activities offered by the club. Further, I understand that, if I am an employee or student at the Institution, this Release, Waiver of Liability, and Covenant Not to Sue shall be effective during the entire period of my enrollment or employment at the Institution. I certify that I am years of age and suffering under no legal disabilities and that I have read the above carefully before signing.*

I accept

ACTION REQUIRED: I hereby agree to remain drug and alcohol free as long as I am participating in Hicks Prep Club. I agree to inform Staff immediately when I am given medication that may affect my behavior. I also agree no to sell or associate with anyone involved in the sale or usage of drugs. If arrested for such involvement of sale or usage of drugs or alcohol, I understand that this forfeits my rights as a member of Hicks Prep Club and possible eligibility for the Hicks Scholars.*

I accept

ACTION REQUIRED: PUBLICITY WAIVER We agree to give Hicks Prep Club permission to use our picture or comments, if obtained in a Hicks Prep Club sponsored program. If used, this picture or comment will in no way embarrass the member or put them in an uncomfortable or compromising position.*

The Zero Tolerance Policy requires proper and appropriate dress and behavior at all times while attending a Hicks Prep Club and Scholarship Program event including transportation to and from the event (such as meetings, field trips, seminars, ceremonies, after school program, etc.) I do here by understand and agree to abide by the following policy. 1. All Students are required to act in an orderly fashion. No running or horseplay will be tolerated, nor will cigarette smoking, alcoholic beverages, or illegal drugs will be allowed at any time. Inappropriate language of any kind, such as swearing, name-calling, talking back to adults, etc., will not be tolerated. 2. During all functions, students will not be allowed to leave the group without appropriate adult supervision and/or permission. 3. CD players, radios, MP3 player and other electronic devices will only be permitted at functions prior to the start or during transportation. Please refrain from use during the event. 4. Cell phones are to be kept on Silent or Vibrate during events. Prep Club members are not to use their phones during any event. The only acceptable use of a cell phone is to contact parents after the event has completed. During special events (dinners, ceremonies, etc.), all participants must adhere to the following dress code: Gentlemen: Conservative shirts (w/tie when requested) and pants required. No tank tops or shorts. Ladies: Modest attire is required. This entails wearing conservative dresses, skirts, slacks, or caprice. Appropriate conservative tops or blouses are required. Shorts and halter tops are not permitted at special events. Please Note: This is the student’s and parent’s only warning. Therefore, if a student displays behavioral problems at any level, the result will be their termination from the Hicks Prep Club and Scholarship Program. All dismissals will occur immediately. Dismissal from the Hicks Prep Club and Scholarship Program will also exclude a student from receiving the Hicks Scholarship. All the rules listed above are subject to revision at any time deemed necessary by the Hicks Prep Club and Scholarship Program Advisory Board, Parent Advisory Council, and/or Staff.*

I understand and accept that it is the policy of the Hicks Prep Club and Scholarship Program Zero tolerance Policy that we must demonstrate positive standards of behavior during meetings, during travel (bus transportation), and at all functions

The Zero Tolerance Policy requires proper and appropriate dress and behavior at all times while attending a Hicks Prep Club and Scholarship Program event including transportation to and from the event (such as meetings, field trips, seminars, ceremonies, after school program, etc.) I do here by understand and agree to abide by the following policy. 1. All Students are required to act in an orderly fashion. No running or horseplay will be tolerated, nor will cigarette smoking, alcoholic beverages, or illegal drugs will be allowed at any time. Inappropriate language of any kind, such as swearing, name-calling, talking back to adults, etc., will not be tolerated. 2. During all functions, students will not be allowed to leave the group without appropriate adult supervision and/or permission. 3. CD players, radios, MP3 player and other electronic devices will only be permitted at functions prior to the start or during transportation. Please refrain from use during the event. 4. Cell phones are to be kept on Silent or Vibrate during events. Prep Club members are not to use their phones during any event. The only acceptable use of a cell phone is to contact parents after the event has completed. During special events (dinners, ceremonies, etc.), all participants must adhere to the following dress code: Gentlemen: Conservative shirts (w/tie when requested) and pants required. No tank tops or shorts. Ladies: Modest attire is required. This entails wearing conservative dresses, skirts, slacks, or caprice. Appropriate conservative tops or blouses are required. Shorts and halter tops are not permitted at special events. Please Note: This is the student’s and parent’s only warning. Therefore, if a student displays behavioral problems at any level, the result will be their termination from the Hicks Prep Club and Scholarship Program. All dismissals will occur immediately. Dismissal from the Hicks Prep Club and Scholarship Program will also exclude a student from receiving the Hicks Scholarship. All the rules listed above are subject to revision at any time deemed necessary by the Hicks Prep Club and Scholarship Program Advisory Board, Parent Advisory Council, and/or Staff.*

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