Youth Registration for Box City Event

Youth Registration for Box City Event

Please provide parent, student, and emergency medical information to complete the registration.
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Student Information
Student Full Name

First NameLast Name
Student Age
Grade
Student Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Relationship to Student
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Parent/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Information
Emergency Contact Full Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Medical Information
Does the student have any allergies?
If yes, please list the allergies.
Does the student take any regular medications?
If yes, please list medications and instructions.
Other medical concerns or special needs
Family Physician Name

First NameLast Name
Family Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Insurance Provider (if applicable)
Medical Insurance Policy Number (if applicable)
Parent/Guardian Authorization and Consent
Parent/Guardian Signature
The participant or their legal guardian, hereby releases, waives, and discharges Haven of Hope, its officers, directors, employees, volunteers, and the City of Van Wert from any and all liability, claims, or causes of action arising out of participation in the Box City event at Fountain Park. By signing this waiver, the participant acknowledges that staying overnight in an outdoor public setting involves inherent risks, including but not limited to weather exposure, uneven terrain, and interactions with the public. The participant assumes full responsibility for any bodily injury, personal property damage, or loss that may occur. Furthermore, the participant agrees to indemnify and hold harmless the aforementioned parties from any expenses or attorney fees resulting from any claims brought by the participant or on their behalf.
Signature
Should be Empty:

Youth Registration for Box City Event

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Student Information

Parent/Guardian Information

Emergency Contact Information

Emergency Medical Information

Parent/Guardian Authorization and Consent