MCDC Youth Program Registration Form

MCDC Youth Programs Registration Form
Date

MonthDayYear
Participant Name
D.O.B
Sex (M or F)
Age
Address
City
State
Zip
Parent/Guardian
Phone
Address (if different from child)
City
State
Zip
Employer
Work Ph
Telephone
Hospital Preference
Medications
Allergies
If your child has physical or mental conditions staff should be aware of, please explain below.

Pick-Up & Emergency Authorization-The following people can be contacted for pick-up or emergency.

EMERGENCY MEDICAL AUTHORIZATION

It is by my signature that I authorize Memorial CDC youth staff/volunteers to seek emergency medical treatment for my child if I cannot be reached or if a delay in reaching my child will be a danger to him or her.
Parent/Guardian Signature

Clear
Name of Child
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Transportation Authorization

My child has my permission to ride in a vehicle operated by a MCDC staff/volunteers representing the youth program. In the event of an accident, I will not hold MCDC/MBC staff responsible for any injuries or damages incurred.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Media Release

I agree that MCDC may use my child's image in any photos, videos, or other media release that may be used in local newspapers, news stations, internet, or any other presentations designed by MCDC.
Name of Child
Parent/Guardian Signature

Clear
Address: 645 Canal St. Evansville, IN 47713 Phone: 812-423-2500

Sponsored by City of Evansville CDBG.

This institution is an equal opportunity provider and employer.
Should be Empty:

MCDC Youth Programs Registration Form