Teens to Queens Summer Registration

Teen's Name *

First Name Last Name
Teens to Queens Summer Registration Form

Registration Fee: $20 | per event
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
School Name *
Grade *
Grade 13 signfies college level
T-Shirt Size *
Please be aware of the difference in youth and adult sizes. Youth will be signified by a (Y).
Does your teen have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is your teen prescribed an inhaler? If yes, please explain any instructions.
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Contact Number *

Area Code Phone Number
Parent/Guardian E-mail *
example@example.com
Emergency Contact's Name *

First Name Last Name
Emergency Contact's Relationship to Teen *
Emergency Contact's Number

Area Code Phone Number
Teen Phone number

Area Code Phone Number
Other Information

Medical information
Do you have health insurance?

Yes No
Insurance Provider *
Put N/A if you do not have insurance.
Policy Holder's Name *

First Name Last Name
Policy Number *
N/a if you do not have this information
Group Number
N/a if you do not have this information
Wavier and Consent Acknowledgements

Be sure to read the following statements thoroughly and check each consent box. Your signature will be required at the end of form.

Permission and Waiver Acknowledgement

I hereby give my approval for my child’s Teens to Queens, Inc. during the selected camp. In exchange for the acceptance of said child’s candidacy by Teens to Queens, Inc., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Teens to Queens, Inc. . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In consideration for being allowed to participate in “2021 Teens to Queens, Inc. Summit”, (this Activity), I release from liability and waive my right to sue Teens to Queens, Inc., their employees, officers, volunteers and agents (collectively “Organization”) from any and all claims, including claims of the Organization’s negligence, resulting in any physical injury, illness (including death) or economic loss I may suffer or which may result from my child’s participation in this Activity, travel to and from the Activity (including air travel), or any events incidental to this Activity. My child is voluntarily participating in this Activity. I understand that there are risks associated with their participation in this Activity, such as physical and/or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, death or economic loss. These injuries or outcomes may arise from my child’s own or other’s actions, inactions, or negligence, or the condition of the Activity location (s) or facility (ies). Nonetheless, I assume all risks of my child’s participation in this Activity, whether known or unknown to me, including travel to and from the Activity (including air travel) or any events incidental to this Activity. I agree to hold the Organization harmless from any and all claims, loss or damage to my personal property, liabilities and costs, including attorney’s fees, as a result of my participation in this Activity, including travel to and from the Activity (including air travel) or any events incidental to this Activity. If the Organization incurs any of these types of expenses, I agree to reimburse the Organization. I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing the Organization from all liability, (b) waiving my right to sue the Organization, (c) and assuming all risks of participating in this Activity, including travel to and from the Activity (including air travel) or any events incidental to this Activity. “If I need medical treatment as a result of my participation in this Activity, travel to and from the Activity (including air travel), or any events incidental to this Activity, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware that the Organization does not provide health insurance for me and that I should carry my own health insurance. I am the parent or legal guardian of the Participant. I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing the District from all liability on my and the Participant’s behalf, (b) waiving my and the Participants’ right to sue the Organization, (c) and assuming all risks of Participant’s participation in this Activity, including travel to and from the Activity (including air travel) or any events incidental to this Activity. I allow the Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of the Participant as described in this document. I agree to be bound by the terms of this document.
Consent *

I have read and agree to the Permission and Waiver Acknowledgement
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the {Organization} . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Consent *

I have read and agree to the Medical Release and Authorization.
Date

Month Day Year
Authorization of Consent for Media Publication

I hereby authorize Teens to Queens, Inc. to edit, alter, copy, exhibit, distribute and publish in print, video, audio recorded productions, and on the World Wide Web this material for purposes of publicizing Teens to Queens, Inc. programs or other lawful purpose without payment or any other consideration. Also I give consent for my child to participate in full to all events/activities outlined by Teens to Queens, Inc.
Consent *

I have read and agree to the Authorization of Consent for Media Publication.
PARENT/GUARDIAN SIGNATURE *

Clear
Should be Empty:

Teens to Queens Summer Registration Form

Other Information

Wavier and Consent Acknowledgements