Eastside Youth Coalition - Participant Registration
EMPOWERING THE NEXT GENERATION! Please fill out this form to participate in EYC programming. Signatures are needed by both the parent/guardian and participant.
It is expected that each youth and adult, not only adhere to the Code of Conduct during sponsored events, but they also hold themselves to a higher standard within all Eastside Youth Coalition’s interactions.It is expected that each youth leader be treated with respect. As an organization we are committed to providing Black, Latinx, Youth of Color racially and culturally relevant programs in a safe community where their lives are valued.
Parent - Guardian Name
Secondary Parent - Guardian Name
Please select a month
Please select a day
Please select a year
Street Address Line 2
State / Province
Postal / Zip Code
Alternative Contact Number
Emergency Contact Number:
Check the program you are participating in:
Eastside Black Girls for Change
Youth and Government
Ground Breakers 2.0
Get Your College On
As the parent/legal guardian, I give full authorization to the Eastside Youth Coalition staff or designated adult leaders to secure medical care or treatment for the participant named above. This treatment may include assistance from the nearest physician, medical clinic, hospital, trained nurse or EMT in the event of illness or injury that requires immediate attention, as determined by the event staff. In the event the participant asnamed above is injured or become seriously ill and I cannot be reached, I authorize any and all hospitalization, medical, dental and/or surgical treatment advisable by the circumstances. I understand that as a parent/legal guardian, I will be responsible for the cost of any service or treatment provided. The Eastside Youth Coalition will not cover costs incurred. I understand that some activities may require travel outside of the city/county limits, State of Washington, and/or across international borders and will be notified by a permission slip prior to said event(s).
Is this participant currently covered by Medical Insurance?
If insured, please provide plan name and policy number:
Health Authorization Signature (Parent):
Photo - Video - Information Release
Permission is granted for photographs and video of my student taken during his/her participation in Youth Eastside Coalition program(s) as well as his/her information (including but not limited to name, grade and school) to be used for purposes that may include publicity. Further this information may be used without compensation. (Not required to participate in programming.)
Information Release Signature (Parent/Guardian):
Code of Conduct:
• It is expected that each youth and adult, not only adhere to the Code of Conduct during sponsored events, but they also hold themselves to a higher standard within all Eastside Youth Coalition’s interactions.• It is expected that each youth leader be treated with respect. As an organization we will focus on our mission that is committed to providing Black, Latinx, Youth Of Color racially and culturally relevant programs in a safe community where theirlives are values.• Sex, alcohol, drugs, tobacco, and violent/malicious behavior will not be tolerated.▪ Sex includes but is not limited to any physical sexual behavior between individuals, sexually explicit comments/innuendos, and/or sharing of any sexual images.▪ Alcohol includes, but not limited to purchasing, consuming or distributing any alcoholic beverage.▪ Drugs includes, but not limited to purchasing, distribution, or use of any illegal substance or prescription drug not prescribed to the intended user.▪ Tobacco includes, but not limited to purchasing, distribution or use of any tobacco product.▪ Violence/Malicious Behavior includes, but not limited to: any physical contact that causes injury to others or self, any threat of physical injury to others or self, any intentional bullying, virtual bullying, name calling or ostracizing of any teen or adult.
Code of Conduct Signature (signed by Student/Participant):
Liability - Release Statement
In consideration of being permitted to utilize the facilities, services and programs of the Eastside Youth Coalition for my student to so participate,for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the Eastside Youth Coalition, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program.It is further warranted that such entry into the for observation or use of any facilities or services or participation in such affiliated programconstitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected andcarefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, useor participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION ORUSE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:1. THE UNDERSIGNED ON HIS OR HER BEHALF AND BEHALF OF SUCH STUDENTS, HEREBY RELEASES, WAIVES, DISCHARGES AND CONVENANTS NOT TO SUE the Eastside Youth Coalition and a thereof, its directors, officers, employees, and agents (hereinafter referred to as"releasees") from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the ordinary negligence of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with Rainier Athletes.2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any, loss, liability, damage or cost they may, incur due to the presence of the undersigned or such children in, upon or about any premises used by Eastside Youth Coalition or in any way observing or using any facilities or participating in any program affiliated with the Eastside Youth Coalition whether caused by the ordinary negligence of the releasees or otherwise.3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to ordinary negligence of releasees or otherwise while in, about or upon the premises of any used by Eastside Youth Coalition and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the Eastside Youth Coalition.THE UNDERSIGNED further expressly agrees that the foregoing RELEASE WAIVER AND INDEMNITY AGREEMENT is intended to be as broad andinclusive as is permitted by the law of the State of Washington and that if any portion thereof is held invalid, it is agreed that the balance shall,not withstanding, continue in full legal force and effect.THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.
Liability - Release Signature (Parent/Guardian):
Should be Empty: