EBSA YOUTH HUB Youth Membership & Parent/Guardian Enrollment Form

EBSA YOUTH HUB Youth Membership & Parent/Guardian Enrollment Form

Emerging Bright Stars Academy (EBSA) Everett Haitian Community Center (EHCC) Thank you for joining the EBSA Youth Hub! This form help us maintain a safe, welcoming, and supportive environment for all participating youth. A parent or a legal guardian should complete this form for participants under 18 Contact us: 857-399-5375 Info@theehcc.org 467 Broadway Everett Ma 02149
Youth Member's Full Name

First NameLast Name
Youth Member's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Youth Member's Email Address
example@example.com
Youth Member's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Full Name

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

Street Address

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

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
School Information
School Attended
School City
Youth Release Authorization
Youth Release Authorization
Names of parents or guardians approved to pick up the youth
Please list any allergies or medical conditions
Can the youth participate in field trips and off-site activities?
PARTICIPATION & LIABILITY WAIVER I, the undersigned parent/legal guardian, give permission for my child to participate in activities, programs, workshops, recreational activities, educational activities, field trips, community activities, and other programming offered through the EBSA Youth Hub and/or Everett Haitian Community Center (EHCC).I understand that participation in youth programming and recreational activities may involve ordinary risks, including but not limited to minor injuries, falls, physical activity, use of recreational equipment, transportation to or from activities, and interaction with other participants.I understand that EBSA Youth Hub/EHCC will take reasonable steps to provide a safe environment and appropriate supervision. However, I understand that not every risk associated with youth activities can be eliminated.To the extent permitted by applicable law, I acknowledge and accept the ordinary risks associated with my child's participation and agree to release and hold harmless the Everett Haitian Community Center, EBSA Youth Hub, their staff, volunteers, program partners, and representatives from claims arising from my child's participation, except to the extent caused by their negligence, gross negligence, intentional misconduct, or other conduct for which a release cannot legally be given.I understand that this waiver does not remove any rights or protections that cannot legally be waived.
EMERGENCY MEDICAL AUTHORIZATION In the event of an emergency involving my child, I authorize EBSA Youth Hub/EHCC staff to contact emergency services and seek appropriate emergency medical attention when I cannot be reached in a timely manner.I understand that staff will make reasonable efforts to contact me or the emergency contacts listed on this form.
PHOTO, VIDEO & MEDIA RELEASE EBSA Youth Hub/EHCC may photograph or record youth during programs, workshops, events, podcast recordings, community activities, and other approved activities.I give permission for my child to be photographed, filmed, or recorded and for their image, voice, or approved work to be used for EBSA Youth Hub/EHCC promotional, educational, social media, website, newsletter, and community outreach purposes.
TECHNOLOGY & INTERNET USE EBSA Youth Hub may provide access to computers, tablets, internet services, gaming systems, recording equipment, cameras, microphones, and other technology.Youth are expected to use technology responsibly and follow staff instructions.I understand that:Youth must use technology for appropriate purposes.Youth may not intentionally damage equipment.Youth may not access inappropriate or illegal content.Youth may not use technology to bully, threaten, harass, or harm another person.Staff may restrict or suspend technology access when necessary for safety or program purposes.
I, as the parent/guardian, consent to my child’s participation and have provided accurate information
Parent/Guardian Signature
Should be Empty:

EBSA YOUTH HUB Youth Membership & Parent/Guardian Enrollment Form

School Information

Youth Release Authorization