Youth Challenge Inc. Application Form

Youth Challenge Inc.

3735 Memorial Drive, Suite 150 Decatur, GA 30032 678-539-5647
Leadership Program Registration Form

Fee: $100/student
Commitment: Meet 2 Saturdays/month for 4 hours/each
Name

First NameLast Name
Date

MonthDayYear
Date
Age
Grade Level
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
EMAIL
Food Preferences
Food Allergies
Other Allergies
T-Shirt Size
Sweat Shirt Size
Sweat Pants Size

Parental/Guardian Consent and Medical Authorization

Parents and legal guardians must complete this section.
Student's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Legal Guardian

First NameLast Name
Mothers Name

First NameLast Name
Fathers Name

First NameLast Name
Students Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian/Parents Contact Information
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
EMAIL
example@example.com
I authorize the following person(s) to transport my child to and from Youth Challenge gatherings in the event that his legal guardian(s) is unavailable.
Consent and Certification

I, the undersigned being the parent or legal guardian of the student named above, dohereby consent to the participation of my student in the activities which may includecourses, field trips in and outside of the Metropolitan Atlanta Area, and other group activities that are associated with rites of passage programs.
I do not authorize my child (student) to participate in any of the following activities.

Medical Treatment Authorization

I understand that I will be notified in case of a medical emergency involving my child.However, in the event that I cannot be reached, I authorize the calling doctor and theproviding of necessary medical services in the event my child is injured or becomes ill. Iunderstand that the Youth Challenge ROP will not be responsible for medical expensesincurred, but that such expenses will be my responsibility as parent/guardian. I agree to notify the Youth Challenge ROP in the event of any health changes that wouldrestrict my child’s participation in any normal youth activities. I also understand that theadult supervisors reserve the right to restrict my child from any activities that they do notfeel is within the physical capabilities of my child.
Signature of Parent/Guardian

Clear
Date

Clear
ACKNOWLEDGMENT
I have read this entire document and it was fully explained to me by a Youth Challenge representative.
Student Signature

Clear
Signature of Parent/Guardian

Clear
Witness

Clear
Date

Clear

RIGHT TO USE PHOTOGRAPHIC LIKENESS OR MOVING IMAGES RELEASE FORM
I,
(Insert name above) ,grant Youth Challenge, the right to use and publishphotographic likenesses or pictures of me or moving images captured by a video camera orother means. I may be included in the photographic likenesses, pictures, or moving images in whole or in part, in conjunction with my own name, or reproductions thereof, madethrough any medium, including the Internet and social media, for the purpose of advertisingin promotion of Youth Challenge programs. I waive any right that I may have to inspect or approve the finished product or theadvertising or other copy, or the use of the portraits, photographic likenesses of pictures, ormoving images of me.I release Youth Challenge and all persons acting under the direct permission or authority ofYouth Challenge Director from any liability that may arise out of the use of the portraits,photographic likenesses, or moving images if used for the purpose of advertising inpromotion of Youth Challenge.
Dated

Clear
Student Signature

Clear
Name Printed

Clear
Signature of Parent/Guardian

Clear
Witness

Clear
Should be Empty:

Youth Challenge Inc.