JACKSON YOUTH PROGRAM 2022 APPLICATION

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).
Medical Emergency Parent's/Guardian's Initials*
I understand that JACKSON YOUTH PROGRAM will not be responsible for the medical expenses incurred, and that such expenses will be my responsibility as parent/guardian.
Medical Expenses Parent's/Guardian's Initials*
Signature*

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Is this youth presently being treated for an injury or sickness?*
If yes, explain:
Is this youth allergic to any type of food or medication?*
If yes, explain:
Does youth have an Epipen?*
If yes Epipen must be provided
Does youth require a special diet?*
If yes, explain:
Does youth have any behavioral or emotional struggles that we should know about?*
If yes, explain:
Is youth currently taking any medication?*
If yes, please complete attached medication consent form and an authorization for self -administration by child’s physician
If yes, please explain what the medication is for:

Terms of Agreement
I hereby give permission for my child to be photographed during JACKSON Youth Program actvities. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. Childrens’ photos and quotes may be used for publicity purposes I understand that although my child’s photograph may be used for advertising, her identity will not be disclosed, I do not expect compensation and that all photos are the property of JACKSON Youth Program.
Terms of Agreement Photos Parent's/Guardian's Initials*
I am aware that JACKSON Youth Program and its co-organizers are not responsible for lost or damaged personal property.
Terms of Agreement - Lost or damaged personal property: Parent/Guardian Initials *
Tearms of Agreement Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Terms of Agreement Parent/Guardian Signature*

Clear
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Printed Name of Parent/Guardian*
Should be Empty:

JACKSON Youth Program