All-American City Competition Trip Application

All-American City Competition Trip Application

Denver, Colorado
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current School:
Grade:
GPA:
Age:
D.O.B.:
Parent/Guardian Full Name:

First NameLast Name
Parent/Guardian Cell Phone:

Area CodePhone Number
Secondary Phone Number:

Area CodePhone Number
Please provide a copy of your child's insurance card

Browse Files

Cancelof
Emergency Contact Information
Full Name

First NameLast Name
Relationship to Youth:
Contact #:

Area CodePhone Number
Parent/Guardian Signature:
Date

MonthDayYear
Date
YEP Medical Information / Waiver & Consent Form
Youth Name:

First NameLast Name
Please list all prescriptions (including dosages) & over the counter medications currently being used by the youth:
Set forth any special notes concerning the above medication:
Please list any Allergies / Disabilities: Do they have an Epipen? Swimmer? Y/N
- I acknowledge that the prescription medications noted above have been prescribed by __________________________, for use as prescribed on the label.
- The over the counter medications have been listed below are approved by me to be given to ________________________ as needed, and I hereby waive any liability on the part of the City of Riviera Beach in the administration of the same.
Fill in the blank
I hereby represent that the above information is true and accurate and the named applicant is in good health and has my permission to participate in the Youth Council activities. I acknowledge that my child will participate in recreational and physical activities within the program, and The City of Riviera Beach will not be held responsible/liable for any injury from participating in the trip and its related activities. I hereby waive and release the City of Riviera Beach and its agents, servants and employees from any and all liability and claims for damages. In the event of an emergency I hereby give permission to such medical personnel to be contact as well as myself (the parent), and rendering of treatment.
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Signature:
Date

MonthDayYear
Date
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All-American City Competition Trip Payment
College Tour Fee Includes: 4 Full Days, Quad Occupancy Hotel Accommodations, Round Trip Airfare and local Charter Bus, Three Meals Daily, Sightseeing Tours and Activities, College Tour T-Shirt, Four City Staff Chaperones.

$300.00

Total

$0.00

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All-American City Competition Trip Application

Emergency Contact Information

YEP Medical Information / Waiver & Consent Form

My Products

Payment Methods