Participants First Name

Participants Last Name

Youth Phone

Date of birth

Age

Gender

Current School

Grade

Parents/Guardian Name

Relationship to Youth

Phone

Email

Emergency Contact Name

Relationship

Does the Participant have allergies?

Yes

No

Doctor's Phone:

Photo/Video Release

I give permission for my child to be photographed or recorded for program documentation, marketing, or social media.

I do not give permission for my child to be photographed or recorded for program documentation, marketing, or social media.

Transportation Permission

I give permission for my child to be transported by program staff or authorized vehicles.

I do NOT give permission.

Emergency Authorization

I authorize program staff to secure medical treatment for my child in the event of an emergency when I cannot be reached.

Number of Family Members in Home

Printed Name

Parent/Guardian Signature