Youth Organization Enrollment Form

YOUTH ORGANIZATION ENROLLMENT FORM

Program Selection

Select program type:

After-school Weekend program Summer camp

Mentorship Volunteer opportunity

Student Information

Date of birth:    Student ID (if applicable):

Parent / Guardian Information

Relationship to youth:    Primary phone:

Emergency Contacts

Relationship:    Phone:    Alternate phone:

Medical Information

Physician phone:    Insurance carrier:

I authorize program staff to administer non-prescription, age-appropriate medications (e.g., acetaminophen, ibuprofen, topical creams) as reasonably necessary in accordance with provided instructions: Yes No

Permissions, Waiver and Release

Consent to participate: I authorize the named youth to participate in the activities, programs and events organized by the youth organization. I understand participation may involve physical activity and accept responsibility for assessing the youth's ability to participate.

Waiver and release of liability: To the fullest extent permitted by law, I hereby release, waive and forever discharge the organization, its officers, employees, volunteers and agents from any and all liability, claims, demands, or causes of action for injury, illness, loss or damage to person or property arising out of or related to participation, unless caused by the organization's gross negligence or willful misconduct. I agree to indemnify and hold harmless the organization against all claims arising from the youth's conduct.

Emergency medical treatment authorization: If the youth requires emergency medical treatment and a parent/guardian cannot be reached, I authorize the organization to secure and consent to emergency medical care, including transportation to a medical facility. I accept financial responsibility for any emergency medical care.

Photo and Media Release

I grant permission for the organization to photograph, record or otherwise capture images of the youth and to use such images for promotional, educational or informational purposes. I understand images may be used in print and electronic media without compensation. If you DO NOT consent, check here: I do not consent

Transportation Consent

I authorize the organization to provide transportation for my child for program-related activities. I understand transportation may include organization-owned vehicles, contracted vehicles or private vehicles driven by authorized volunteers or staff: Yes No

Fees, Payment and Refunds

Payment option:

Full payment Installment plan Scholarship requested

Refunds: Enrollment fees and tuition are subject to the organization's published refund policy. By signing below, I acknowledge that I have read and accept the organization's fee and refund terms as stated in the enrollment materials and policies provided by the organization.

Code of Conduct Acknowledgment

I acknowledge that the youth must comply with the organization's code of conduct, which includes respectful behavior, non-violence, no possession of illegal substances, and adherence to staff directions. Serious or repeated violations may result in suspension or dismissal from the program without refund.

I have reviewed the code of conduct and accept responsibility for ensuring the youth understands and follows the rules: Acknowledged

Data Privacy and Records

The organization will collect and maintain personal information necessary for program administration. Information will be used for program operations, emergency contact, billing and required reporting. Information will be retained and disclosed only as permitted by law. I consent to the collection and use of the youth's information as described: Consent

Additional Information

Certification and Signature

By signing below I certify that I am the parent/legal guardian or the youth (if age 18 or older). I attest that the information provided on this form is true and complete to the best of my knowledge. I have read, understand and agree to the permissions, releases, policies and acknowledgments contained in this enrollment form.

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