Enrollment Form for The Good Fight Community Center in La Crosse, WI

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Enrollment Form

Please complete the following enrollment form and liability waiver to join The Good Fight Community Center. You can also download and print this enrollment form by clicking here.

Step 1 of 3 - Personal & Emergency Contact Information

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Child's Personal Information
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Hidden
Race
Race*
- White
- Black or African American
- American Indian or Alaska Native
- Asian
- Hispanic/Latinx
Biological Sex*
Home Address*
Street AddressCityStateZIP Code
Parent/Guardian Contact Information
Parent/Guardian First Name*
Parent/Guardian Last Name*
Phone Number*
Email*
Emergency Contact Information
Emergency Contact First Name*
Emergency Contact Last Name*
Relationship to Child*
Emergency Contact Address*
Street AddressCityStateZIP Code
Primary Phone*
Secondary Phone

Medical Questions
Does your student have any medical conditions we should be aware of?*
- Yes
- No
Please explain*
Does your student have any allergies we should be aware of?*
- Yes
- No
Please explain*
Transportation Information
How will your student get to our facility?*
- Parent Drop Off
- Public Transportation
- GFCC Van
- Walk
*** Our GFCC Van only picks up from the public middle schools, Spence Elementary, and Northside Elementary.
How will your student get home from our facility?*
- Parent Pick Up
- Public Transportation
- GFCC Van
- Walk
*** Our GFCC Van only transports home in the city of La Crosse.
Would you like to be contacted if your student leaves the facility before our scheduled end time (Monday-Friday 7:00pm)?*
- Yes
- No
Do you allow your student to attend offsite trips with Good Fight staff? (ex. afternoon movie trip, children's museum, community service, etc.)
- Yes
- No
Student Profile
Name of Student's School*
Student's Grade Level*
Homeroom Teacher
In what subject areas does your student need academic support?*
Does your student have any behavioral issues that we should know about?*
- Yes
- No
What has been the best course of intervention?*
Does you student struggle with social interaction? More specifically are they typically withdrawn or very active in social situations?*
- Yes
- No
What do you hope to see progress made during your student’s time at The Good Fight?*
Is there anything else you would like for the staff of The Good Fight to know, to best support your student?*
Parent/Guardian Signature*

By entering your name above, you agree your electronic signature is the legally binding equivalent to your handwritten signature, and you are also confirming that you are the individual named in the electronic signature, and that you are authorized to sign this document.
Date*
MM slash DD slash YYYY

Liability Waiver
Must be signed prior to participation.
I, the undersigned, do hereby voluntarily participate or have child/children that participate in the Elsworth Smith boxing training program held by The Good Fight Community Center, Inc. I do hereby assume full responsibility for any and all damages my child/children may sustain or incur in any event or activity while participating in boxing, boxing training, or conditioning classes. I do hereby waive all claims against Elsworth Smith Boxing Gym, Larry Shapiro Education and Job Training Center, The Good Fight Community Center, its promoters, sponsors, donors, instructors and trainers, volunteer’s, board of directors, individuals, or others who have taught me.
In the event that a photo is used of me or my child, I give permission for the photo to be used to help promote the community center in print, banners, signs, websites, or any promotion. This agreement shall be binding upon and insure to the benefit of the parties, their successors, assigns and personal representatives.

I understand this liability waiver and understand its terms. I execute it voluntarily and with full knowledge of its significance.
Parent/Guardian Name*
Date*
MM slash DD slash YYYY
Electronic Signature*

By entering your name above, you agree your electronic signature is the legally binding equivalent to your handwritten signature, and you are also confirming that you are the individual named in the electronic signature, and that you are authorized to sign this document.
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