YOUTH PROGRAM REGISTRATION

Childs Name *

Youth Age? *

Youth Birthdate? *

Date

Gender

Male Female

Current Grade

School District

Address

Parent/Guardian Name

Phone

Email Address

Which program are you applying for? *

Build-A-Bike Workshop (Ages 09-17)(February 16,2022 8 Weeks Straight Talk 4 Teen Girls (Ages 09-17) (02/12/2022) 8 Month Mentoring Program Child Advocacy Mentoring Program (Ages 9-17) 8 Weeks (January 17,2022;4:30pm-6:30) Southside Community Center Community Youth Dance Class Sunday 1pm-2:30pm( Southside Community Center) January 23,2022; Classes Wednesday’s from 5pm-7pm(ages 7-17) Reading &Tutoring Program ( Tuesday-Thursday 4pm-7pm) Grades k-12 (Reconcilliation Church) After School Therapeutic Day Treatment Program ages 5-18 Rock Climbing Program 01/03/2022 from 5:30pm-7:30pm ages 9-17 (Space is limited) Mending Stitches Sewing Class for Parent & Child (May 2022) TBD

What is your teen shirt size? Is it a Youth size? *

XS S M L XL XXL

Allergies with brief description of reaction. *

Medical Conditions

Does your child take any medications on a regular basis?

Family Physician Info Phone, Address

Insurance Company

In the case of emergency, I give permission for my child’s health concerns to be discussed between Child Advocacy Mentoring Program staff and his/her health care provider.

Yes No

Emergency Contact 1

Emergency Contact 2

Medical & Photo Release Form.. It is recommended that participants secure adequate medical insurance to cover any injuries that may arise from participation in A Better Day Than Yesterday Initiative Programs( ABDTYIP). I hereby approve myself and/or my child’s participation in the program. I hereby consent to emergency medical treatment for my child on my behalf. In addition, I will assume any and all financial responsibility. To the best of my knowledge, there are no physical and/or other conditions, which would interfere with my child’s participation in such activities .I, the undersigned, hereby release A Better Day Than Yesterday Initiative Program from any liability or claims for injury, illness, or property damage that I sustain and/or cause during my participation, or sustained by my son/daughter/minor in my care participating in this event, program or other which is in any way related. I expressly accept and assume all of the risk inherent in this activity or that might have been caused by the negligence of Releases. Releases are defined as partners, sponsors, officers, members, agents, employees and any other organization, entities, and individuals who are serving A Better Day Than Yesterday Initiative Program including all volunteers assisting with programs, events or other ABDTYIP activities. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Release from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional misconduct. PHOTO RELEASE: I hereby give consent for ABDTYIP, to use photographs and/or videos of my minor child, to be used in its publications, including its website and/or social media. I release A Better Day Than Yesterday Initiative Program LLC. From any expectation of confidentiality or financial reimbursement on behalf of the aforementioned minor child and/or myself. Child Disclaimer and Signature: I certify that my answers are true and complete to the best of my knowledge. *

Agree Disagree

COVID - 19 Release I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that ABDTYIP has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that ABDTYIP can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families. I hereby release and agree to hold ABDTYIP harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself15and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from ABDTYIP. I understand that this release discharges ABDTYIP from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from ABDTYIP. This liability waiver and release extends to the salon together with all owners, partners, and employees. *

Yes No

Signature *

Clear

MEDICAL INFO BELOW