YOUTH (age 12-17) & PARENT REGISTRATION FORM

PARTICIPANT REGISTRATION FORM
Youth Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographics /Race*

Black/AfricanWhite/CaucasianPacific IslanderAsianJapaneseAmerican IndianNative AmericanViatmaneseFilipinoChineseMixedOther
If race not listed above please list here.
Ethnicity*
Are you (youth) currently: (Please check all that apply)

Active MilitaryVeteranType option college studentReceive Cal FreshReceive MediCalDisability
School
Grade Level
Medical Insurance
Insurance Provider Name
Medical Insurance #
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
CONSENT AND RELEASES

LIABILITY RELEASE: In consideration of THE GROWTH CENTER I, INC. allowing the Participant to participate in THE LEVEL UP YOUTH MENTAL WELLNESS events, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless The Growth Center I, Inc, its directors, employees, volunteers, partners, sponsors and agents (collectively herein the “TGC”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the Level UP Youth Mental Wellness events. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in the Level UP Youth Mental Welllness Conference events.
Furthermore, we (I) [and on behalf of our (my) minor child(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved with The Growth Center I, Inc. Level UP Youth Mental Wellness Conference events therein.
Further, authorization and permission is hereby given to said TGC to furnish any necessary transportation (within the limitations of insurance and the law), food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said TGC for any liability sustained by said TGC as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

EARLY RETURN HOME POLICY: Should it be necessary for our (my) child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

*All guests must complete the medical/insurance information. This must be completed in its entirety.
Signature (Consent & Releases)

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Does your child have any allergies? If yes, please list.
Does your child have any medical conditions that we should be aware of? If so please provide details.
Any History of serious illness ( diabetes, asthma, epilepsy, mental health) or recent hospitalization?
MEDICAL TREATMENT PERMISSION: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.
Signature (Medical Treatment)

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Does your child take any medication? If yes Please list medication and dosage.
Signature (by signing agree that my electronic signature gives TGC permission to administer medication to my child per the written dosage I provided).

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Please select dietary plan that best fits your needs
If dietary restrictions are not listed above, please provide more detail here.
Please share anything else we should know about your child.
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship
Will you be attending the parent sessions. These sessions are for parents only.
If yes to the previous question, please select your diet*
Do you have any food allergies? If Yes, Please explain.
My child will need transportation to the conference. (Pick up locations in South Sacramento and Elk Grove). More information to be sent to parent prior to event date.
CONSENT AND RELEASE OF LIABILITY-TRANSPORTATION

Please sign if your child will need transportation to the event.

TRANSPORTATION PERMISSION:

The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in LEVEL UP YOUTH Mental Wellness Conference events hosted by The Growth Center I, Inc. My child/youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation and are responsible for compliance.
Signature (Transportation)

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PHOTO RELEASE:

The undersigned additionally gives permission for The Growth Center I, Inc ists, sponsors and partners to publish photographs or video of my youth on their social media, website, flyers, brochures, newsletters and other platforms for marketing. promotion and advertising purposes.
Signature (Photo Release)

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Signature

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Acknowledgment
- Parent/Guardian registered in this form has legal custody over the child.
- 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 Level Up Youth Mental Wellness Retreat.
- I give permssion for my child to participate in The Growth Center I, Inc. also know as The Growth Center Level UP Youth Mental Wellness Conference.
Parent/Guardian Signature

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Date Signed

MonthDayYear
Date
Should be Empty:

PARTICIPANT REGISTRATION FORM

Parent/Guardian Information

Acknowledgment