Tribal Youth Fitness Registration

Name of Participant

First NameLast Name

Age

Date of Birth

Parent's Name

First NameLast Name

E-mail (parent)

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Where does your child attend school?

Phone Number (Parent)

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact #1

First NameLast Name

Relationship to Emergency Contact #1

Emergency Contact #1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact #2

First NameLast Name

Relationship to Emergency Contact #2

Emergency Contact #2 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please List all medical conditions of which the staff should be aware (eg. Asthma, Diabetes, Epilepsy, Allergies etc. blanks .

Does your child have any conditions that may be affected/exacerbated by exercise
Yes No If, yes please explain, blank .
blanks

Is your child on medication of which exercise in contraindicated (advised against)
Yes No If yes, please explain blank .

Is you child asthmatic Yes No
If he/she is asthmatic, will you be providing the staff with their prescribed inhaler or are they allowed to carry their inhaler with them in order to self-medicate? blank .

This authorization grants permission to use your childs image on social media and website platforms to promote the Intertribal Youth Fitness program and to highlight your childs acheivements.

I give permission for my child's photograph or video to be used

Signature

As the parent/guardian of blanks, I grant permission for his/her to engage in all activities associated with Intertribal Youth Fitness after-school program including the utilization of the facilities and equipment in the Intertribal Fitness Center and activities outside of the facility and/or remote locations. I understand that there are risk associated with the physical activities which are included in this program, as there are with any physical activity. I also understand that this is a physical fitness program and many of the activities are physically rigorous, necessitating an increase in physical exertion including an elevated heart rate. AsI therefore release and hold faultless all employees of TDP/Intertribal Fitness from liability from any injury resulting from my child's participation in the program and activities associated with Intertribal Youth Fitness after-school program.

I also understand that any level of physical activity can place stresses on the body, and I grant permission for my child to participate with full medical clearance.
Date

Parent/Guardian Signature

Intertribal Youth Fitness teaming up with The Zone