Youth Name *
Youth Name
Parent Name *
Parent Name
Phone Number *
Phone Number
(Home, work or cell)
Alternative Phone Number *
Alternative Phone Number
(Home, work or cell)
Address *
Address
YES Media Release *
I give my permission for YES, its agents, employees, or students to take photos of the activities in which the above mentioned minor may be participating. Please note that program photos may be used in YES promotional materials (i.e. brochures, newsletters, press releases, slide shows, videos, television promos and Facebook page). By checking the box below you agree to these terms.
* List persons authorized to pick up your child.
Emergency Contact *
Emergency Contact
Emergency Contact
Phone *
Phone
Emergency Contact Phone
Emergency Contact (2) *
Emergency Contact (2)
Phone *
Phone
Emergency Contact (2) Phone
Does your child take medications? Please list name and dosage. Please write N/A if your child does not take medications.
What, if any, are your child’s allergies? (foods, insects, medications.) Please write N/A if your child does not have any known allergies.
Does your student have any physical, learning, emotional, or other conditions or disabilities (i.e. ADD/ADHD, asthma, autism, diabetes, wheelchair bound, etc. – knowing this information assists us in planning activities/accommodations)? Please list and explain. Please write N/A if your child does not have any conditions or disablities
*
I hereby consent that the above named minor has my permission to participate in the activities planned in conjunction with YES events. I hereby recognize that there may be risks involved with respect to the activities in this program. I hereby assume such risks, and release YES, its agents, employees or youth of any liability. I understand that in the event of a medical emergency, YES staff will make every attempt to contact me. If said attempts are not immediately successful, YES staff may refer the above named minor to a licensed medical practitioner and/or clinic. I hereby consent that such physician, hospital, or clinic may treat the said minor in response to the medical emergency. I hereby release YES, its agents, employees, or students of responsibility for the above named minor in the event that the minor does not follow prescribed treatment for injury/illness. By checking the box below I agree to these terms.