Individual Registration

Please enter information in the form below to process registration for event HOC College Success Program .

Is the participant under 18 years old? *

Yes

Are you an HOC resident or HOC Program Participant?

Yes

Parent Guardian's Name

Parent Guardian's First Name *

Parent Guardian's Last Name *

Participant First Name *

Participant Last Name *

DOB *

Gender *

Female

Male

Grade *

Address *

Address 2

City *

State

Zip *

Telephone *

Primary Language

Email *

In the event of an emergency and we cannot reach you, who should we contact in your place?

Name of Emergency Contact *

Relationship *

Emergency Phone *

Alternate Phone

Is there anything we need to know or any accommodations that your child might require? (Example: Medication or Food Allergies, Medical Considerations, etc.)

MEDIA RELEASE ACKNOWLEDGMENT

First Name *

I consent to allow the Housing Opportunities Commission of Montgomery County (“HOC”), its nominee, or designee to reproduce, distribute, or use my name, photo, and likeness and/or that of my child/children named above, in all forms of media and in all manners, including, but not limited to, advertising, promotional materials (including video), trades, display, editorial, art, and exhibition. In granting this consent, I release HOC, its nominees, and designees, from any and all liability, claims, or obligations which may arise out of the use of such personal information.

Do you give consent? *

Yes

Electronic signature

By clicking this box, you are signing this registration form (including the Terms and Conditions) electronically. You agree that your electronic signature is the legal equivalent of your manual signature.

By clicking this box, you acknowledge that you have read, understand, and accept the Terms and Conditions Terms and Conditions

Verification code*