Emory Registrations 1 Program Selection2 Student Info3 Parent/Guardian Info Program SelectionPrograms that have met their capacity will not show up on the list.Program Info Price: $30.00 Program Selection*Emory Saint Joseph's Hospital 7/1/19 (1 spots left)Emory University Hospital Midtown 7/5/19 (0 spots left)Emory Decatur Hospital 7/29/19 (0 spots left)Emory University Hospital (Clifton) 7/30/19 (0 spots left) Student InformationStudent's Name First Last Date of Birth Date Format: MM slash DD slash YYYY Gender Male Female Current/Rising GradePlease SelectGr 12678910111213141516--None--School Attending*Parent/Guardian InformationName First Last Address/Billing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* Enter Email Confirm Email Are there any special circumstances you would like us to be aware of?Cancellation Policy*Transfers – In order to transfer payment to another program date, we must be provided a minimum of a seven-day notice. We will only transfer payment one time. Refunds – Notification at least two weeks prior to program date will be eligible for a refund minus a $10 service fee. Late cancellations are not eligible for a refund. No Shows – No prior notification will result in forfeit of payment and may not be transferred. I have read and understand the cancellation policy. Liability Waiver*Liability Release and Parental Consent Form - In consideration for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me or my child as a result of participation in said event. This release is intended to discharge in advance the Jonathan D. Rosen Family Foundation, its officials, officers, trustees, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees. I have read and understand the above liability release and agree to all of its terms and conditions. Photo Release*I hereby authorize the Jonathan D. Rosen Family Foundation to publish the photographs taken of me and/or the registered minor child, and our names, for use in the Wealthy Habits website and for display in other marketing materials. I release the JDRFF from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the child register and that I have the authority to authorize the JDRFF to use their photographs and names. I acknowledge that since participation in publications and websites produced is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by the JDRFF confers no rights of ownership whatsoever. I release its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the registered minor child. I agree I do not agree Additional PurchasesWould you like to add a Wealthy Habits T-shirt? $10OPTIONALNo Thank YouYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-LargePurchase Total $0.00 Coupon Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.