Youth Enrollment Form

* Indicates required field

Name *

First

Last

Gender Identification *

School Name & Grade *

Birthday & Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent/Guardian Name *

Parent/Guardian Contact Phone Number *

Parent/Guardian Email Address *

Emergency Contact Information (If Different from Parent/Guardian Info Above) *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Phone Number *

Is your youth presently being treated for an injury, sickness, or taking any form of medication for any reason? *

Yes No

If Yes, Please explain: *

Is your child allergic to any type of food or medication? *

Yes No

If yes, please list below: *

Medical Release Information: Name of Health Care Provider & Contact Information *

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. *

I understand that Humanity Hale or any of it’s affiliates will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian *

Please share any past or current traumas or issues your child may be experiencing, (this will help us better serve them. Please remember, this is a non-judgement zone, we do not condemn parents or guardians for this information, we all have trauma and anything you share with us is only used to help, never hurt you or the child.) *

Please list all approved adults, who are permitted to pick up your child: *

Terms of Agreement Photo Release I hereby give my permission for my child to be photographed during the workshop sessions. I understand the photos will be used to keep a journal of activities to share during power point presentation and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not I do not expect compensation and that all photos are the property of the Humanity Hale. *

Transportation Release I hereby give permission for the transportation of my child for official Youth Sessions activities by modes of transportation agreed to by the Humanity Hale organizers. *

Humanity Hale and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. Students’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family member cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). I understand, acknowledge and agree that Humanity Hale, will provide for reasonable supervision of students within its care and control. The supervision will be consistent with the ages of the students. However, the Humanity Hale Board is not an insurer of the safety of the students nor can it supervise all movements of all students at all times. In addition, there are certain risks inherent in travel and at the destination. I further understand that an employee or volunteer has no personal liability unless he or she has acted recklessly, wantonly, or intentionally to injure my child. *

Parent/Guardian Signature (Type Your Name In) & Date: