Quest Youth Development Participation Registration

Participant's Name*

First NameLast Name

Birth Date

MonthDayYear

Grade*

What school does your child attend?*

Will your child need to be transported from their school to Quest Youth Development Center located at 200 E Lake Avenue, New Carlisle Ohio 45344? (PARENTS THAT PICKUP MUST SHOW ID AT PICKUP)

YESNO

Will your give your child permission to be transported home by a vetted Quest Youth Development volunteer?

YESNO

Will your give your child permission to be transported to other venues by Quest Youth Development for programming?

YESNO

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number

Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Who is the participant's primary physician?*

What is the preferred hospital for your participant?*

What programs interest your child?*

Quest Youth Development

Waiver, Release of Liability, Media Release, & Hold Harmless Agreement

Quest Youth Development is a program of Jobseekers Network. Quest Youth Development programs utilize trained, certified, and background checked Direct Service Professionals.

By signing below, you agree that you have read this disclaimer and agree to allow your child to participate in age appropriate programs that include life skills, education, leadership, career development sessions provided by Jobseekers Network, Quest Youth Development. You also agree to allow your child to participate in after school programs and or weekend programs.

MEDIA RELEASE FORM

I, grant permission to Jobseekers Network dba, Quest Youth Development, hereinafter known as the “Media” to use my image (photographs and/or video) for use in Media publications including: Videos, Email Blasts, Recruiting Brochures, Newsletters, Magazines, General Publications, Website, Social Media Channels and/or Affiliates

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.

I am 20 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

or

I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

PARTICIPATION WAIVER & RELEASE OF LIABILITY

In consideration for being allowed to participate in programs for the Quest Youth Development organization, Jobseekers Network, LLC, , I hereby release, waive, discharge and covenant not to sue the Quest Youth Development, Jobseekers Network, LLC, Lawrenceville Church of God Organization, Tecumseh Local Schools, Clark County Jobs & Family Services, officers, board members, coaches, instructors, mentors, volunteers, and agents, (collectively "Organization") from any and all liability claims, demands, actions, and causes of actions. This includes claims of the Organization's negligence, resulting in physical injury, illness (including COVID-19 and or death), or economic loss that I may suffer, or which may result from my participation in the program, travel to and from any and all activities associated with the Organization, and any events incidental to the Organization. In exchange for the opportunity of my child being allowed to participate in a Jobseekers Network dba, Quest Youth Development Program, I agree as follows:

1. I am the Legal Guardian of the participant who has qualified for and is being allowed to participate in a Jobseekers Network dba, Quest Youth Development Program.

2. On behalf of my spouse, minor child, our heirs, executors, administrators and assigns, hereby waive, release and forever discharge the Jobseekers Network dba, Quest Youth Development, its officers, directors, employees, volunteers and sponsors from legal liability any and all actions, suits, damages, claims or judgments for damages or expenses that may result from any personal injury, loss of property or property damage, or any other claim, demand, action or right of action, of whatever kind or nature, either in law or in equity, regardless of fault, arising from or by reason of my child being allowed to participate and compete in a Jobseekers Network dba, Quest Youth Development;

3. In consenting or releasing for my minor child, I (we) do further hereby agree to protect Jobseekers Network dba, Quest Youth Development, its officers, directors, employees, volunteers, and sponsors, against any actions, claims or demands by said minor child or by any other person or persons on account of damages of any character resulting in any way from said minor child’s participation and competing in a Jobseekers Network dba, Quest Youth Development. We also hereby agree to reimburse and make good to Jobseekers Network dba, Quest Youth Development any loss, damage or costs it may have to pay as a result of any such action, claim or demand.

4. Should it be required during the Jobseekers Network dba, Quest Youth Development programs; I acknowledge that I authorize medical treatment of my child by a qualified medical professional.

5. I, the undersigned, further expressly agree that the foregoing release, waiver, and indemnity agreement is intended to be as broad as inclusive as is permitted by law, and that if any portion of it is held invalid by the appropriate court of competent jurisdiction, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

6. I, the releasor, have read and voluntarily sign this release and waiver of liability and indemnity agreement, and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement have been made.

7. I, the releasor, further state that I am of lawful age, am legally competent, and have full legal authority to sign this affirmation and release on behalf of my minor child; that I understand the terms herein are contractual and not a mere recital; and that I have signed this document as my own free act.

8. I, the releasor, have fully informed myself of the contents of this affirmation, waiver, and release by reading it before signing it with full knowledge of its significance, intending to be legally bound thereby; and

9. I, the releasor, agree that should any lawsuit or other action, regardless of the nature of the claim arise under this agreement, it shall be brought in a court of competent jurisdiction within the Clark or Miami County Ohio and tried without a jury. All parties to this agreement hereby submit to the jurisdiction of such courts.

By signing below, I acknowledge that as the parent/guardian of the minor participant, I am voluntarily signing as my own free act and have received, read, and fully understand and agree to all terms and conditions of this waiver.

HOLD HARMLESS AGREEMENT

I further agree to indemnify and hold harmless the Quest Youth Development, Jobseekers Network, LLC, Lawrenceville Church of God Organization, Tecumseh Local Schools, Clark County Jobs & Family Services, officers, board members, coaches, instructors, mentors, volunteers, and agents,, from any loss, damage, liability, or costs, including court costs and attorneys' fees that the Organization(s) may incur as a result of participation in this activity, whether caused by negligence or otherwise. I acknowledge that like job that utilizes equipment has a certain amount of inherent danger and risk involved. I hereby assume all of the risks of participating in any and all activities associated with the Organizations. I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such activities, whether caused by the negligence of the Organization or otherwise.

Medical Release and Authorization

As Parent and/or Guardian of the named paricipant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the Jobseekers Network, Quest Youth Development staff and volunteers, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participant. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Jobseekers Network, Quest Youth Development. and its affiliates to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered programs.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date*

Date

Signature*

Participant Registration

Participant Information