Youth Registration Form
(For Parents)
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
Insurance Provider Name
Medical Insurance #
Does the youth have any allergies?
Does the youth 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.
Email
*
example@example.com
Relationship
*
Secondary Name
First Name
Last Name
Secondary Phone Number
Please enter a valid phone number.
Secondary Email
example@example.com
Secondary Relationship
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
I am responsible for transporting my child to and from youth activities.
I am responsible for picking up my child in a timely manner from youth activities. Repeated failure to do so may result in suspension or expulsion from the program.
I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.
The repeated offense of the youth or myself may result in suspension or expulsion from the program.
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: