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Envision Academy 601 E. Trade Street Charlotte, NC 28202

CMPD Youth EnVision Academy

Summer Academy Application

Name of Participant

Full Address

If you are attending Summer School, please provide dates:

Parent / Guardian Information

Parent / Guardian Name

Full Address

Parent / Guardian Consent

I do hereby consent and agree that Youth Envision Academy, and any of their affiliates, has permission to take photographs and/or audio of my child and/or my child’s property to use for Youth Envision Academy educational, promotional, and/or marketing materials. I further consent that their name and identity may be revealed therein or by descriptive text or commentary.  Neither individual addresses nor telephone numbers will be published within these materials. 

I do hereby give the Youth Envision Academy the right to exhibit any such works publicly or privately, including posting on the CMPD Website.

I waive any rights, claims, or interest I may have to control the use of my child’s identity or likeness in the photographs, video or audio and agree that any uses described herein may be made without compensation or additional consideration to me or my child.
I represent that I have read and understand the foregoing statement and I am competent to execute this agreement.

Parent / Guardian Signature

Choose how to sign

Please submit this application to your Youth Envision Academy liaison/agency representative along with a letter of recommendation from your HS School Counselor, Teacher, SRO or Program Coordinator.

Upload Letter of Recommendation from your High School Counselor, Teacher, SRO or Program Coordinator

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