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) 7 Weeks Straight Talk 4 Teen Girls (Ages 13-17) 9 Months Straight Talk 4 Jr. Teen Girls (Ages 9-12) 9 Months Child Obesity Workout Class (Ages 9-17) 8 Weeks Reading & Tutoring Program ( Tuesday-Thursday) Grades k-12 After School Therapeutic Day Treatment Program ages 5-18

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

XS S M L XL XXL

Will the child need transportation to and from the workshop?

Yes No

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

Policy/ID Number:

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

Signature

Clear

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