Youth Name *
Youth Name
List persons authorized to pick up your child:
Emergency Contact (1)
Emergency Contact (1)
Phone Number *
Phone Number
Emergency Contact (2) *
Emergency Contact (2)
Phone Number *
Phone Number
Does your child take medications? Please list name and dosage.
What, if any, are your child’s allergies (foods, insects, medications)?
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.
*
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.