Adultish Participant Waiver
Youth's Name
*
First Name
Last Name
Preferred Pronouns:
Date of Birth
*
-
Month
-
Day
Year
Date
Legal Guardian's Name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Emergency Contact (Emergency contacts are required to be either a guardian, close relative, therapist or county worker)
*
First Name
Last Name
Type of Contact
*
Please Select
Parent
Sister/Brother
Aunt/Uncle
Grandparents
Therapist
County Worker
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Emergency Contact 2
First Name
Last Name
Type of Contact
Please Select
Parent
Sister/Brother
Aunt/Uncle
Grandparents
Therapist
County Worker
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Allergies/Special Instructions
Any mental health/sensory/safety needs
Do you consent to your child to go on field trips in walking distance of Thumbs Up?
*
Yes
No
If yes, please sign here.
I acknowledge and understand that this group is provided by volunteers of Thumbs Up and cannot be a replacement for mental health treatment. There will be no recommendations made for mental health treatment, should you have concerns that your child needs mental health support, please call your primary care provider or a local mental health specialist. Feel welcomed to ask one of the volunteers for information on local mental health resources. Waiver of Liability: I understand that by signing this Waiver of Liability, I release any hold Thumbs UpHigh 5K, Inc., its owners, directors, employees, instructors, and volunteers, and all other persons partnering with them from any and all claims, demands, suits, cost and charges, in connection with organizing out of hold Thumbs Up High 5K, Inc. including but not limited to, personal injury, bodily harm, injury, or property damage occurring while the above youth is/are in their care at Thumbs Up High 5K,Inc. Adultish is not able to provide one-on-one supervision, and is a drop-in-group, meaning that attendees come and go at their own discretion. While Thumbs Up staff, volunteers and all persons related to Thumbs Up will prioritize respecting attendees’ confidentiality; health and safety are of the utmost importance to us.Therefore, by signing this agreement you are consenting to allowThumbs Up staff and/or volunteers to reach out to either or both emergency contacts to discuss any potential safety/health concerns as well as regular check-ins to allow Thumbs Up staff/volunteers to best support the attendee. Attendees will be unable to attend/participate in any thumbs up groups until the participant waiver is filled out in its entirety.
*
Date
*
-
Month
-
Day
Year
Date
Submit
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