The Gem in Me Registration Form
Youth Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade Level
Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
Parent/Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
If a chaperone or driver is needed, I'll do that.
I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.
Parent/Guardian registered in this form has legal custody over the child.
I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult on board.
For medical emergencies, I allow the medical team of this organization to take care of my child.
I release this organization from any and all liability from accident or injury to the child during the organization related events.
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: