TBK at HYCC Consent and Release Form

Take Back the Kitchen - Teen Summer Series

Registration & Consent Form
HYCC has partnered with Haley House to host four FREE sessions of Haley House's Take Back the Kitchen (TBK) program. TBK is a cooking and nutrition program that promotes the joy and health benefits of cooking food from scratch.

Teens 14 - 18 are encouraged to join us on Thursdays at 4:30 pm for the following dates:

June 6, 2024

June 13, 2024

June 20, 2024

June 27, 2024

For any session attended students will be given a $30 stipend for participating.

Participation Consent & Release Form

TAKE BACK THE KITCHEN (TBK) Haley House, Inc.

Program Description: Participants will learn how (with the supervision of adults) cook healthy meals and learn about the benefits of healthy ingredients.

Activity Location: 9 Fulda St. Roxbury, MA

Partnering Organization: Hawthorne Youth & Community Center, Inc.

This form is to be completed by the parent or guardian of minor participants (under 18 years of age) in Haley House, Inc. Take Back the Kitchen activities. This form must be completed and returned prior to participation.
Name of Participant*
Age*
Date of Birth*

MonthDayYear
Date
Participant Email*
example@example.com
Participants Home Address*
Zip Code*
Please select which dates the teen intends to participate*

Thur, June 6th @ 4:30pmThur, June 13th @ 4:30pmThur, June 20th @ 4:30pmThur, June 27th @ 4:30pm
Name of Parent/Guardian (1)*
Parent/Guardian (1) Phone*
Parent/Guardian Email*
example@example.com
Name of Parent/Guardian (2)
Parent/Guardian (2) Phone
Additional Emergency Contact*
Full Name
Emergency Contact Phone*
If the participant has any food allergies or other medical concerns of which we should be made aware please list: (Write N/A if there are none)*
Parental / Participant Release
In signing this form, I hereby certify that the above information is correct and give permission for my child or myself to participate in this activity. I hereby agree that no liability is assumed by Haley House, Inc. or its representatives for claims which may arise out of this activity.

In signing this form, I also certify that my child and I have read and agree to abide by Take Back the Kitchen Ground Rules and Dress Code.
Medical Release*

In the case of a medical emergency, I understand that every effort will be made to contact the parent or guardian of the participant. In the event that a parent or guardian cannot be reached, I hereby give permission for the participant to be transported to a medical facility where proper treatment and care will be provided.
Photo Release*

I DO give permission for photos of my child (or myself) taken during this activity to be used for the promotion and benefit of Take Back the Kitchen and Haley House.I DO NOT give permission for photos of my child (or myself) taken during this activity to be used for the promotion and benefit of Take Back the Kitchen and Haley House.
Signature of Parent/Guardian (or self if 18+)*
Date*

MonthDayYear
Date
Should be Empty:

Take Back the Kitchen - Teen Summer Series

Parental / Participant Release