UBY Youth Nights Registration 2025-2026

2025-2026 UBY Youth Nights

Youth Nights are for children in grades K-8th grade.
How many children are you registering?*
Child Information
First Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Current Grade*
School Name*
Medical or other information we may need to know about the child (including food allergies).*
Emergency Medical Authorization
I, Parent/Guardian's Name*, parent or legal guardian of Child's Name*, born Date of Birth* , do hereby consent any first aid or medical care determined by a physician to be necessary for the welfare of my child while said child is under the care of Upward Bound Youth (UBY) and I am not reasonably available by telephone to give consent. This authorization is effective from September 2025 to September 2026.

Signature* Date*
Second Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Current Grade*
School Name*
Medical or other information we may need to know about the child (including food allergies).*
Emergency Medical Authorization
I, Parent/Guardian's Name*, parent or legal guardian of Child's Name*, born Date of Birth* , do hereby consent any first aid or medical care determined by a physician to be necessary for the welfare of my child while said child is under the care of Upward Bound Youth (UBY) and I am not reasonably available by telephone to give consent. This authorization is effective from September 2025 to September 2026.

Signature* Date*
Third Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Current Grade*
School Name*
Medical or other information we may need to know about the child (including food allergies).*
Emergency Medical Authorization
I, Parent/Guardian's Name*, parent or legal guardian of Child's Name*, born Date of Birth* , do hereby consent any first aid or medical care determined by a physician to be necessary for the welfare of my child while said child is under the care of Upward Bound Youth (UBY) and I am not reasonably available by telephone to give consent. This authorization is effective from September 2025 to September 2026.

Signature* Date*
Fourth Child
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Current Grade*
School Name*
Medical or other information we may need to know about the child (including food allergies).*
Emergency Medical Authorization
I, Parent/Guardian's Name*, parent or legal guardian of Child's Name*, born Date of Birth* , do hereby consent any first aid or medical care determined by a physician to be necessary for the welfare of my child while said child is under the care of Upward Bound Youth (UBY) and I am not reasonably available by telephone to give consent. This authorization is effective from September 2025 to September 2026.

Signature* Date*
Parent/Legal Guardian Information
Parent/Legal Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Emergency Contact 1 (other than parent/guardian listed above)*

First NameLast Name
Emergency Contact 1 Phone Number*

Area CodePhone Number
Relationship to child(ren)*
Emergency Contact 2 (other than parent/guardian)*

First NameLast Name
Emergency Contact 2 Phone Number*

Area CodePhone Number
Relationship to child(ren)*
Transportation

transportation is limited but MAY be available based on needs.
Do you have a way to transport your child(ren) to and from Youth Nights?*

YesNo, I do not have reliable transportation
Please Select 1 of the following:*

My child(ren) will not be able to attend Youth Nights without transportation TO and FROM the eventI can drop off my child(ren) but would need transportation FROM the event in order to attendI can pick up my child(ren) but need transportation TO the event in order to attend
Cell Phone Policy

To ensure a focused, engaged and respectful environment during UBY Youth Nights, we have implemented a cell phone policy. Please read and agree to the following:
Policy:

1. Cell Phone Usage:
- Best practice is to have your child leave their cell phone at home. If you need to reach your child while they are at Youth Night, UBY Staff will be accessible via the texting number (330-680-7908) or the UBY Office number (330-345-1991).
- Cell phones brought on site must be turned off or set to silent mode and kept out of sight during all UBY Youth Night activities including dinner, stations, memory verse and traveling in UBY vehicles to and from the event.
2. Consequence:
- First Violation: Verbal reminder from UBY Staff or Volunteer.
- Second Violation: Cell phone will be locked in the UBY Office until the end of the Youth Night.
- Repeated Violations: Parents/guardians will be contacted, and further action may be taken based on the situation.
Exceptions:

If you or your child have a specific need requiring the use of a cell phone (e.g., medical reasons), please discuss the situation with the Program Director (Sam Stone) to make appropriate arrangements.
By clicking the box below, I acknowledge that I have read and agree to the UBY Cell Phone Policy and will inform my child(ren) of said policy.*

I Agree
Media Release
By clicking the box below, I hereby Give Permission for photographs and/or video in which my child(ren) appears in to be used by Upward Bound Youth in printed and/or electronic media, including but not limited to: publicity, advertising, and web content without any compensation for such use.

I Agree
Liability Waiver
The undersigned does hereby give permission for my child(ren) to attend and participate in all UBY Youth Night events during the 2025-2026 calendar year. The undersigned will not hold Upward Bound Youth (UBY), its staff or the volunteers present liable for any accidents or injury incurred during activities. All participants participate at their own risk. The undersigned will also notify the adult leadership of UBY prior to any event of any changes to the information contained on this form. By signing below the undersigned agrees that to the extent they sign electronically, their electronic signature is the legally binding equivalent to their handwritten signature.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Name of Signer*

First NameLast Name
Should be Empty:

2025-2026 UBY Youth Nights

Child Information

First Child

Emergency Medical Authorization

Second Child

Emergency Medical Authorization

Third Child

Emergency Medical Authorization

Fourth Child

Emergency Medical Authorization

Parent/Legal Guardian Information

Transportation

Cell Phone Policy

Media Release

Liability Waiver