Clone of UBY Discipleship Program 2026

UBY Pickleball Clinic Registration
Upward Bound Youth will be offering several pickleball clinics for students in 5th–12th grade.

During each clinic, students will have the opportunity to interact with UBY staff and other students while learning and developing their pickleball skills. Students will learn how to play pickleball and participate in athletic training, pickleball-specific instruction, and practice designed to help them grow as athletes. Throughout the evening, students will also have the opportunity to hear about Jesus and learn how the Gospel connects to their lives.
How many children are you registering?
Which Pickleball Clinic Will Your Child(ren) Attend?
Child Information
First Child
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Gender
Current Grade
School Name
Church
What is your child's experience level with pickleball? (Examples: Never played before, familiar with the basic rules, plays recreationally, or competes competitively.)
Medical Information
Family Doctor
Doctor’s Phone
Preferred Hospital
Insurance Carrier
Daily Medications
Allergies or Other Specific Medical Concerns
Medical or other information we may need to know about the child.
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.

Signature* Date*
Second Child
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Gender
Current Grade
School Name
Church
What is your child's experience level with pickleball? (Examples: Never played before, familiar with the basic rules, plays recreationally, or competes competitively.)
Medical Information
Family Doctor
Doctor’s Phone
Preferred Hospital
Insurance Carrier
Daily Medications
Allergies or Other Specific Medical Concerns
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.

Signature* Date*
Third Child
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Gender
Current Grade
School Name
Church
What is your child's experience level with pickleball? (Examples: Never played before, familiar with the basic rules, plays recreationally, or competes competitively.)
Medical Information
Family Doctor
Doctor’s Phone
Preferred Hospital
Insurance Carrier
Daily Medications
Allergies or Other Specific Medical Concerns
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.

Signature* Date*
Fourth Child
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Gender
Current Grade
School Name
Church
What is your child's experience level with pickleball? (Examples: Never played before, familiar with the basic rules, plays recreationally, or competes competitively.)
Medical Information
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.

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

First NameLast Name
Email
example@example.com
I would like to receive updates on Upward Bound Youth events and Youth Nights via email:
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)
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.
Liability Waiver
The undersigned does hereby give permission for my child(ren) to attend and participate in the Upward Bound Youth Pickleball Clinic. 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 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.

By signing this agreement, I acknowledge that participation in pickleball and related activities at Upward Bound Youth may involve physical exertion and inherent risks, including but not limited to slips, falls, collisions, equipment failure, and personal injury.

I give permission for my child to receive necessary medical treatment in the event of an injury or medical emergency that occurs while participating in Upward Bound Youth activities. I understand that reasonable efforts will be made to contact me or another emergency contact before treatment when possible.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Signer

First NameLast Name
Should be Empty:

UBY Pickleball Clinic Registration

Child Information

First Child

Medical Information

Emergency Medical Authorization

Second Child

Medical Information

Emergency Medical Authorization

Third Child

Medical Information

Emergency Medical Authorization

Fourth Child

Medical Information

Emergency Medical Authorization

Parent/Legal Guardian Information

Media Release

Liability Waiver