Youth Participant Form [2025]

1
Who are you signing for?* This field is required.The Austin17House is a judgment free resource facility that encourages creativity and supportive programming for both middle and high school aged youth and families. To ensure that the youth have a safe environment to enjoy, we ask that you please fill out as much information on this waiver as you can so that we can better serve you and your child.
I am signing for myself
I am signing for my youth
2
Participant name* This field is required.
First Name
Last Name
3
Participant's birthdate* This field is required.
Date
Month
Day
Year
4
Participant's Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Middle/High school participant attends* This field is required.
6
Emergency Contacts* This field is required.
Emergency Contact full name
Emergency Contact phone number (Numbers only)
Emergency Contact email
Physician Name (N/A if non-applicable)
Physician phone number (N/A if non-applicable)
7
Does the participant have any allergies (i.e. pollens, medications, foods, insects)* This field is required.
YESNO
8
Allergen Details
9
Does the participant suffer from, or has ever experienced, or is being treated currently for any of the following (please select all that apply):
Asthma
Epilepsy/Seizure disorder
Heart trouble
Diabetes
Frequent upset stomach
Physical handicap
10
Should the participant's activities be restricted for any reasons? If yes, please explain.* This field is required.
YESNO
11
Participant Restrictions
12
If necessary, please describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability or condition to which the participant is subject and of which the staff should be aware of, and if any action of protection is required as a result.
13
Austin17House is aware of many of the social determinants that affect our youth and families today, and we work closely with organizations and partners to ensure that all participants and members who join us have options for support where needed. As a non-profit organization we also have opportunities to receive grants and donations for families who are in any public assistance programs.Does your family participate in any public assistance programs?
Free and reduced price school (breakfast, lunch, supper)
TANF
Food pantry/Soup kitchen
Public housing/Section 8
Food stamps/SNAP
WIC/CSFP
Heat/Electric assistance
SSDI
Head start
Town welfare
Medicaid
SSI
Wrap around services
IEP
504
Other
14
Photo & social media release* This field is required.I authorize and grant Austin17House the right to use, adapt, make copies, distribute, and publicly display, in any format now known or later developed, all photographs and videos taken of me or my child, by A17H, without present or future compensation. I further agree that any photographs taken of me or my child may be reproduced in any materials, including newsletters, web sites, or social media intended to publicize A17H events or activities.
YESNO
15
For your information; We expect each participant to respect these rules of conduct

- No possession or use of alcohol, drugs, and/or tobacco products including e-cigarettes and juul products
- Students are not allowed to leave and come back to the center without parent permission
- No fighting, weapons, fireworks, lighters, or explosives
- No offensive or indecent clothing
- No offensive language
- No public displays of affection
- Participation during group activities is suggested
- Respect property
- Respect others, staff and volunteers
- Respect and comply with event schedules and rules

*Students who fail to comply with these expectations will receive an incident report that a volunteer must provide and communicate to the parent.
16
I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth activities. I agree to respect the expectations laid out above.* This field is required.Please have the participant sign
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17
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Austin 17 house (A17H) and its volunteers from any liability against personal losses of name child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by A17H. I/We understand that there are inherent risks involved in any community center or athletic event, and I/we hereby release A17H, it's volunteers, staff and board members from any liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement.* This field is required.
I agreeI disagree
18
In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by A17H. I/we acknowledge that we will ultimately be responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above through the date listed on this form.* This field is required.
I agreeI disagree
19
I/we also, hereby give permission for my child to take over the counter medication (Tylenol, Ibuprofen, Tums, etc.) at the recommended dosage. Please indicate any/all over the counter medication your child is allergic to or you do not give permission to take. Please specify if it is an allergy.* This field is required.
I agreeI disagree
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Additional Notes
21
Austin17House is committed to providing youth, families and volunteers with an environment that is free from discrimination and unlawful harassment. Actions, Words, Jokes or Comments based on individual's Sex, Race, Ethnicity, Age, Religion will not be tolerated. A17H encourages volunteers to bring any incidents of sexual harassment to the immediate attention of the Executive Director.* This field is required.
I confirm I have read and agree to reach out to the Executive Director to make any sexual harassment claims.
22
Additional waivers required for participation in relevant activities for the rooms listed belowPlease select any waivers that you would like to sign
Workshop waiver
Fitness room waiver
Beekeeping waiver
23
I understand that blacksmithing, woodworking, and shop are inherently dangerous activities and acknowledge that there are risks inherent in their practice, including without limitation:(1) the use of and exposure to hot coals and high temperature iron and steel (2) handling hot metals and flux (3) exposure to sharp objects (4) exposure to power tools (5) exposure to falling objects I understand that my negligence or failure to act within my abilities may contribute to or result in an injury.
I agree (and confirm that youth is at least 12 years old)
24
I understand that using workout equipment is an inherently dangerous activity and acknowledge that there are risks inherent in its practice, including but not limited to exposure to sharp objects, exposure to falling objects, or risk of falling.
I agree (and confirm that participant is at least 12 years old)
25
I understand that beekeeping is an inherently dangerous activity and acknowledge that there are risks inherent in its practice, including but without limitation:(1) the use of and exposure to heated tools and equipment (2) the possibility of bee stings which could potentially result in an allergic reaction in affected individuals (3) exposure to sharp objects and tools (4) exposure to power tools (5) exposure to falling objects
I agree (and confirm that participant is at least 12 years old)
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ReleaseAUSTIN17HOUSE ("A17H") hereby specifically disclaims any and all responsibility or liability for, and I hereby irrevocably release A17H from, any and all claims, whether known or unknown, which I may have relating to: (i) any and all damages to the student or any personal property of the student, including without limitation, indirect and consequential damages or injuries as a direct or indirect result of the inherent risks of metal working; (ii) any liability relating to instruction, construction, design, use of any A17H equipment or facilities, manufacture of any product, or any other activity undertaken in conjunction with classes, workshops or seminars offered by A17H or as a result of the use or application of information given or contained in any class, workshop or seminar offered by A17H or contained in any writing given to me by A17H or (iii) any actions taken by me while on the A17H premises with respect to construction, design, use of equipment or facilities or manufacture of any product.
I agree
27
Additional Waivers SignatureI hereby represent and warrant that I understand that by signing this document, I may be waiving certain legal rights. I understand that I will be responsible for all actions taken at the A17H facilities, including without limitation, use of equipment and facilities. I understand that I am solely responsible for any and all damages, whether direct or consequential, for the use and application of information given at any seminar, workshop or class or contained in any writing distributed by A17H.
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28
Parent/Guardian informationParent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
First Name
Last Name
Relation to participant
phone number
email address
29
Today's Date* This field is required.
Date
Month
Day
Year
30
Parent or Guardian's signature* This field is required.
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31
Electronic Signature Consent* This field is required.By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
I agree
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