Youth Summit 2026 Registration

Participant Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Age*
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Church/Group (If your child is attending with a church or other club/group, please list the name of that church/group here.)
Parent/Guardian Information

This person will also serve as the Emergency Contact.
Parent Name/Emergency Contact*

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The Youth Media and Photo Release Agreement

The undersigned parent/guardian does agree to grant The Brightside Project permission to record on film, video tape or audio tape the above listed participant at the Youth Summit. He or she further agrees that any or all of the material recorded may be used in any form, social media use and future event promotional materials made by The Brightside Project and that such use shall be without payment of fees, royalties, special credit or other compensation. This form shall be valid until such time that it is revoked by the undersigned.
I agree to the Youth Media and Photo Release above.*

YesNo
Permission & Agreement

The undersigned parent/guardian grants permission for the above listed participant to attend the Youth Summit on Saturday, March 14 from 9am-6pm. and agrees to identify and hold harmless The Brightside Project, event partners, sponsors and affiliates from any claim for damages resulting to the above listed participant, unless said injuries were proven to be the result of negligence of The Brightside Project, event sponsors, partners or affiliates.

Emergency Medical Authorization

Revised 5/6/2020 | This form meets the requirement for Ohio Revised Code Section 3313.712. Programs may use this form or build their own.
Part I - TO GRANT CONSENT

I hereby give consent for the following medical care providers and local hospitals to be called:
Doctor Name

First NameLast Name
Doctor Phone
Please enter a valid phone number.
Dentist Name

First NameLast Name
Dentist Phone
Please enter a valid phone number.
Medical Specialist Name

First NameLast Name
Medical Specialist Phone
Please enter a valid phone number.
Local Hospital
Emergency Room Phone
Please enter a valid phone number.
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for: (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Facts concerning the child's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted:
Signature of Parent/Guardian
Date

MonthDayYear
Date
PART II - REFUSAL TO CONSENT

I do *NOT* give my consent for emergency medical treatment of my child.
In the event of illness or injury requiring emergency treatment, I wish the school or organization authorities to take the following action (written instructions must be completed):
Signature
Date

MonthDayYear
Date
Should be Empty:

Participant Information

Parent/Guardian Information

The Youth Media and Photo Release Agreement

Permission & Agreement

Emergency Medical Authorization

Part I - TO GRANT CONSENT

PART II - REFUSAL TO CONSENT