2023 SPARK Summer Excursions Registration

2023 SPARK Summer Excursions Registration Form

Please carefully fill out all fields below to register your youth for summer outdoor adventures.
Is a school staff/SFA helping fill out this form?*

YesNo
Contact Information

Please complete the information below
Participant's (Youth) Name*

First NameLast Name
Participant's (Youth) Date of Birth*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Parent/ Guardian Phone Number*
Please enter a valid phone number.
Parent/guardian email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Choose your adventure(s)!
*PLEASE READ: Programs that are listed as "FULL" may still be selected; we will add you to the waitlist for that program and contact you if/when a space opens up.
Which adventure(s) do you/your youth want to attend? Select ALL that apply.*

"Glamping" campout (Thursday, June 8 - Friday, June 9) FULL - will be added to waitlist.Top Ropes Rock Climbing (Friday, June 23) FULL - will be added to waitlist.Kayak + Camp Overnight near Des Moines (Thursday, July 6- Friday, July 7) - FULL - will be added to waitlist.Maquoketa River Day Float (Friday, July 21) - FULL - will be added to waitlist.Mirror Lake State Park, Wisconsin. (Monday, July 31-Thursday, August 3) - FULL - will be added to waitlist.Yellow River 3-Day Backpacking Experience (October 13-15th, fall break) - FULL - will be added to waitlist.

Emergency Information

Please complete information below
In the event there is an emergency related to your child, please provide at minimum 1 person whom you would authorize to act on your behalf if we were unable to reach you.
Primary Emergency Contact Person (please list someone other than yourself)*

First NameLast Name
Primary Emergency Contact Person Phone Number*
Please enter a valid phone number.
Primary Emergency Contact Person's relationship to you or your child
Do you have an additional person you would like to list as another emergency contact?*

YesNo
Secondary Emergency Contact Person (please list someone other than yourself)

First NameLast Name
Secondary Emergency Contact Person Phone Number
Please enter a valid phone number.
Secondary Emergency Contact Person's relationship to you or your child
In the event of an emergency I authorize the emergency contact person(s) listed above to act on my behalf when you are unable to reach me.
Please click button below to verify that you have read the statement above and you acknowledge the statement as the parent/legal guardian of the child named on this form.*

I have read and acknowledged the statement above and I authorize consent for the emergency contact person(s) listed above to act on my behalf when you are unable to reach me.

Medical Consent for Emergency Treatment
In the event that my child may require medical, dental and/or surgical care while I am unable to be reached, I hereby give my consent for medical, dental and/or surgical treatment. I agree to pay all costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent.
Please click button below to verify that you have read the statement above and you acknowledge the statement as the parent/legal guardian of the child named on this form.*
In the case of a medical emergency that requires transport to an area hospital please indicate your preference from the choices below.*

University of Iowa Hospitals and ClinicsMercy HospitalNo preference

Release of Liability and Assumption of Risk Agreement

Please read the following statements and select the acknowledgement statement
(1) I certify that my child is physically capable of participating in outdoor programming and that I will disclose any physical limitations or medical problems which might limit his/her/their capability to perform under the normal conditions of programming. United Action for Youth reserves the right to deny anyone the opportunity to participate where questions exist regarding one’s physical capability to safely participate in the program.
Please click button below to verify that you have read the statement above and you acknowledge the statement as the parent/legal guardian of the child named on this form.*

I have read and acknowledged the statement (1) above
I wish to disclose any physical limitations or medical problems that may limit my child's participation in the programming.*

YesNo
Please use the space below to disclose any physical limitations or medical problems that may limit your child's participation in the programming.
(2) I hereby understand that my child personally assumes all risks in connection with participation in SPARK programming and hereby releases, waives, and forever discharges United Action for Youth and their employees, agents, program partners, volunteers and representatives (Releasees) from any and all liability of any and every nature whatsoever, including claims or suits at law or in equity that I may have, for any and all personal injury, including death, and property loss or damage that may result from, arise out of, or be related to my participation in the programming, including any travel to and/or from the program site. I hereby agrees to indemnify and hold harmless the Releasees from such liability whether injury, loss or damage is caused by my negligence, the negligence of the Releasees, or the negligence of any third party.
Please click button below to verify that you have read the statement above and you acknowledge the statement as the parent/legal guardian of the child named on this form.*

I have read and acknowledged the statement (2) above
(3) United Action for Youth may take photographs, videos and/or audio record my image and/or voice to use in promoting the purpose of the program. I understand that no financial benefits from the use of the photographs, videos and/or audio record are obligated to be paid to me.
Please click button below to verify that you have read the statement above and you acknowledge the statement as the parent/legal guardian of the child named on this form.*

I have read and acknowledged the statement (3) aboveI have read the statement and choose to decline having my photo, video, and/or audio record my image and/or voice used by United Action for Youth.
I have read this emergency medical treatment consent form, release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.
Parent/guardian signature (please type)*
As a school staff or student-family advocate, I certify that I have filled out this form in conjunction with a parent/guardian; that all the information provided is theirs; and was input with their permission. I understand that a typed name in the box below functions as a legal signature.
School staff signature (please type name)
Should be Empty:

2023 SPARK Summer Excursions Registration Form

Contact Information

Choose your adventure(s)!

Emergency Information

Medical Consent for Emergency Treatment

Release of Liability and Assumption of Risk Agreement