Coach Kenyatte's Roots & Roads™ Student Registration

Step 1

Academic Year

Registering for *

Step 2

Parent/Guardian 1

First name *

Last name *

Email *

Phone *

Home address *

Work/Business

Optional, helpful for sponsorship and community partnerships.

Employer/Business name

Job title

Work phone

What do you do? (brief description)

Step 3

Parent/Guardian 2

Complete if applicable (Optional)

First name

Last name

Phone

Work/Business

Optional, helpful for sponsorship and community partnerships.

Employer/Business name

Job title

Work phone

What do you do? (brief description)

Step 4

Emergency Contact

Add each emergency contact (someone other than the parents listed above).

Emergency Contact 1

Full name *

Phone *

Relationship to student *

Step 5

Student Information

Add each student you're enrolling.

Student 1

First name *

Last name *

Date of birth *

Grade (entering) *

Current school

Program track *

Was this student in the 2025–2026 pilot program? *

YesNo

Allergies

Medical notes/medications

Meal restrictions/dietary needs

This student needs program transportation

Step 6

Releases & Agreements

Photo/media release

I grant permission for my student to be photographed or recorded during Coach Kenyatte's Roots & Roads™ program activities for use in promotional materials. I release Coach Kenyatte's Roots & Roads™, its staff, volunteers, and partners from any liability related to the capture, use, or distribution of such media.

Transportation release

I authorize Coach Kenyatte's Roots & Roads™ program staff to transport my student to and from program activities and field trips. I understand that travel involves inherent risks, and I release Coach Kenyatte's Roots & Roads™, its staff, drivers, and partners from any liability for injury, loss, or damage that may occur during transportation, except in cases of gross negligence.

Meal program consent

I consent to my student receiving meals and snacks provided by the program. Program staff will make an effort to attend to the dietary information I've provided; however, I understand that my student is still responsible for making the appropriate dietary choices for their specific needs. I release Coach Kenyatte's Roots & Roads™ and its staff from any liability regarding dietary needs, allergies, or reactions.

Program fees agreement *

I understand that program fees apply for the selected academic year and agree to remit payment per the published and chosen schedule. I understand that fees are non-refundable except as expressly stated by Coach Kenyatte's Roots & Roads™, and I release the program from any liability related to fee disputes, scheduling changes, or program adjustments made in good faith.

Step 7

Comments, Concerns, and Suggestions

Share anything else, including who you feel Coach Kenyatte should connect with

Step 8

Parent/Guardian Signature(s)

Parent/Guardian 1 signature is required. Parent/Guardian 2 may also sign if applicable.

By entering your names below, both parents/guardians acknowledge that you have read, understood, and agree to all releases, consents, and fee terms listed above on behalf of the enrolled student(s).

Parent/Guardian 1, type full name as signature *

Parent/Guardian 2, type full name as signature

Date *