Select a Program:
School-Boys
School-Girls
Community-Boys
Community-Girls
Leadership-Boys
Leadership-Girls
Jump Start
Celebrate
Girls Guide to Life

Payments may be cash or check (made out to OPBI) and is accepted by mail or at the door. Mail to: 5509 W Gray Street, Suite 100, Tampa, FL 33609.

*Community sites are all non-school programs.

Participant Information

First Name

Last Name

Home Mailing Address

City

State
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Other

Zip

Gender
Male      Female

Grade Level
Select a Grade Level 1 2 3 4 5 6 7 8 9 10 11 12

Birthday (month | day | year)
Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Ethnicity

American Indian or Alaskan Native     
Asian
Black or African-American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander  
White
Other

Any Medical or Special Needs?

Caregiver Information

First Name

Last Name

Home Phone Number

Mobile Phone Number

Email Address

Confirm Email Address

Emergency Contact Name

Emergency Contact Phone

Household Adults Over 18

Mother
Father
Foster Parent
Grandparent
Other

Mother’s Educational Level  

Some High School
Completed High School
Some College
Completed 4 Year Degree
Graduate or Professional School

Father’s Educational Level  

Some High School
Completed High School
Some College
Completed 4 Year Degree
Graduate or Professional School

Permissions

Media/Photo Release

I DO grant permission to The Ophelia Project and Boys Initiative – Tampa Bay to use photographs and videotapes taken of my child.

I DO NOT grant permission to The Ophelia Project and Boys Initiative – Tampa Bay to use photographs and videotapes taken of my child.

Mailing List

Receive exciting news about upcoming events, programs for girls and educational presentations for adults.

I DO grant permission to OPBI, INC. to add my name to the mailing list.

I DO NOT grant permission to OPBI, INC. to add my name to the mailing list.

Authorization for Emergency Medical Treatment

If my child should become ill or injured during the conference I understand that I will be contacted immediately or the contact person I have designated about, if I cannot be reached. Should OPBI be unable to reach me or the emergency contact, they are authorized to arrange for immediate emergency treatment necessary to ensure my child's health and safety.

I DO AGREE to all terms and conditions listed in the 'Authorization for Emergency Medial Treatment'.

Permission for Enrollment and Release of OPBI, Inc. from Liability

I am an adult over 18 years of age and I give my child permission to participate in OPBI, INC. activities. I understand that even when every reasonable precaution is taken, accidents can sometimes still happen. Therefore, in exchange for OPBI, INC. allowing my child to participate in OPBI, INC. activities, I understand and expressly acknowledge that I release the OPBI INC. and its staff members from all liability for any injury, loss or damage connected in any way whatsoever to my child's participation in OPBI INC. activities whether on or off the OPBI INC. premises. I understand that this release includes any claims based on negligence, action or inaction of the OPBI INC., its staff, directors, members and guests. I have read and am voluntarily signing this authorization and release. I HAVE READ THIS FORM AND GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL ACTIVITIES PROVIDED BY OPBI, INC. By signing this form, I state that I am the legal guardian/parent of the minor child listed above and authorized to grant such permission.

I DO AGREE to all terms and conditions listed in the 'Permission for Enrollment and Release of OPBI, Inc. from Liability'.