2024 Zeta Phi Beta Sorority, Inc Youth Club Membership Application

Youth Club Membership Application
Child's Information:

First NameMiddle InitialLast Name
Date of Birth:

MonthDayYearAge
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
School Name:
Grade:
Hobbies and/or Special Interest:
Hobbies and/or Special Interest: (continued)
Parent/Guardian's Information:

First NameMiddle InitialLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number:
(If none type N/A)Format: (000) 000-0000.
Cell Number:
(If none type N/A)Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact:
Relationship:
Phone Number:
(If none type N/A)Format: (000) 000-0000.
I, Parent/Guardian's Name* hereby confirm that my child, Child's Name* has my permission to become an active member of the * Youth Club of Zeta Phi Beta Sorority, Inc. Lambda Delta Zeta Chapter.
Parent's Signature:
Chapter Name

Informed Consent & Release of Liability

I hereby release and hold harmless Zeta Phi Beta Sorority, Incorporated, Lambda Delta Zeta Chapter, its agents, representatives, and employees (collectively and individually Zeta Phi Beta Sorority, Incorporated) from any and all liability which may arise in connection with my participation in any and all activities sponsored by Zeta Phi Beta Sorority, Incorporated, or any other offices, departments, or organizations associated with Zeta Phi Beta Sorority, Incorporated. Such activities so sponsored shall be referred to as Programs. This release shall include but shall not be limited to potential liability from accidents or injuries which may occur in connection with or potential liability from the content of any and all Programs. Furthermore, I agree to indemnify Zeta Phi Beta Sorority, Incorporated, Lambda Delta Zeta Chapter from any suit, claim or any other action brought by any parent, whether biological, adoptive or custodial, guardian or family member of any youth participating in any Program on account of or in connection with my participation in any and all Programs. I understand that Zeta Phi Beta Sorority, Incorporated, is not responsible for determining whether the content of any Program is suitable for the participants but that such determination shall be made by the participant. I declare that I have read completely the terms of this Release and that I understand fully and voluntarily accept each and every term of this Release.
Chapter Name
Chapter Name
Chapter Name
I, Parent/Guardian's Name* hereby confirm that my child, Child's Name* has my permission to attend meetings, activities, trips and events for the * Youth Club of Zeta Phi Beta Sorority, Inc. Lambda Delta Zeta Chapter from July 2024 to June 2025. It is my understanding that these activities, which are taken under auspices of the Zeta Phi Beta Sorority, Inc. Lambda Delta Zeta Chapter will be supervised by competent members who will travel with the group.
Year 1
Year 2
Chapter Name
Chapter Name
Chapter Name
Chapter Name
Parent/Guardian's Information:

First NameMiddle InitialLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Signature:

Youth Liability Form: Medical Release pg 1
I/We, Parent/Guardian's Name* are the parent(s)/guardian(s) of Child's Name* . After having fully considered the possibilities of harm arising out of or in connection with reasons of illness,
injury, accident or death incurred or suffered by our child’s participation during the meeting, activities,
events, trips, service projects of the Youth Auxiliary, I/we, as the parent(s)/guardian(s) do accept the responsibility for any and all injury to our child which may occur during
travel, participation in activities, and any other time during the scheduled and planned events. I/We certify that our child is in good health, and free from any disability that would make her participation in the program/conference inadvisable.
As the parent/legal guardian, I request that in my absence the above named child be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic, operative procedures and x-ray treatment of the above minor.
I have read this release and indemnification agreement and understand its meaning. This release is intended to bind my heirs, representatives, successors, assigns and administrations.
Chapter Name
Parent/Guardian's Name:

First NameMiddle InitialLast Name
Parent's Signature:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Physician:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Carrier:
Policy Number:
Group Number:
#1Emergency Contact       Relationship Phone Number
#2Emergency Contact    Relationship   Phone Number
#3Emergency Contact     Relationship     Phone Number
Chapter Name

Youth Liability Form: Medical Release pg 2
Child's Name:
Chapter Name
Date of Birth:

MonthDayYear
Date
Please list any known allergies (medication, food, etc.):
Details of any of the above and any other important medical information:
Is your child currently taking any medications?

List of Medications:

Rows	Medication	Dosage	Times Per Day	Conditions
1.
2.
3.

List any medical problems which should be noted:
Parent's Signature:

YOUTH CLUB PHOTO RELEASE FORM

I grant Zeta Phi Beta Sorority, Inc. the unlimited right to use and/or reproduce photographs or likenesses in any legal manner for the internal or external promotional and information activities of Zeta Phi Beta Sorority, Inc. I also agree to allow my child to be interviewed and/or photographed by representatives of the external news media in relation to any and all coverage of Zeta Phi Beta Sorority, Inc. in which she is involved. I also agree to allow my child’s work and/or photograph to be published on the Zeta Phi Beta Sorority, Inc. national and local chapter Web site/Internet pages, and publications. I further understand that by signing this release, I waive any and all present or future compensation rights to the use of the above stated material(s).
Child's Name:
First Name, MI, Last Name
Parent/Guardian's Name

First NameMiddle InitialLast Name
Parent's Signature:
Chapter Name
Should be Empty:

Youth Club Membership Application

Informed Consent & Release of Liability

Youth Liability Form: Medical Release pg 1

Youth Liability Form: Medical Release pg 2

YOUTH CLUB PHOTO RELEASE FORM