Registration for Youth Explosion

Student Name

First NameLast Name
Age
Grade
Please list any allergies
- Student Name
  
  First NameLast Name
- Age
- Grade
- Please list any allergies
- Student Name
  
  First NameLast Name
- Age
- Grade
- Please list any allergies
- Parent Name
  
  First NameLast Name
- Parent Email
- Parent Phone #
  Please enter a valid phone number.Format: (000) 000-0000.
- Emergency Contact Name
  
  First NameLast Name
- Emergency Phone #
  Please enter a valid phone number.Format: (000) 000-0000.
- I hereby grant Youth Explosion of Bartow County and its representatives the irrevocable right and permission to photograph, video record, and/or otherwise capture my image, likeness, and/or voice in connection with Youth Explosion. I authorize the use, reproduction, editing, and publication of these photos, videos, and recordings in any medium (including print, digital, and online) for lawful promotional, educational, advertising, or informational purposes, without further notice, compensation, or approval from me. I understand that all such recordings will be the property of Youth Explosion. I hereby waive any right to inspect or approve the finished product or any use in which my likeness appears and release Youth Explosion from any and all claims arising out of or in connection with the use of these materials. I am the parent or legal guardian of the minor(s) named above and I consent to the terms of this Photo and Video Release on their behalf.
- Should be Empty: