Parent Permission Statement

By signing this statement, you agree to the following:

I understand that YU activities will be during school days and weekends.
I give permission for my child to participate in the activity and follow the rules and instructions of the supervisor.
I understand and accept the benefits and risks of the activity and release the organizer from any liability for any injury, loss, or damage that may occur during the activity.
I authorize the Youth United School Advisor to seek medical attention for my child in case of an emergency and agree to pay for any expenses incurred.
I allow the Youth United organizer to use any photos or videos of my child taken during the activity for promotional or educational purposes.
I release and hold harmless United Way of the Capital Area or their representatives from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury, including but not limited to personal injury, sustain as a result of my child participating in the Youth United Ambassador Program.

Child's Name

First

Last

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Parent or Guardian Name

Title

First

Last

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Parent or Guardian Phone Number

Parent or Guardian Email

Medical Information

Additionally, we kindly request you to inform us of any special medical or dietary considerations that we should be aware of to ensure your child’s safety and well-being during the program.

Does your child have any medical conditions, allergies, or special needs that we should be aware of? If yes, please explain:

Does your child take any medication regularly? If yes, please list the name, dosage, and frequency of the medication:

Does your child have any dietary restrictions or preferences? If yes, please specify:

Is your child covered by any health insurance? If yes, please provide the name and policy number of the insurance company:

Emergency Contact

Title

First

Last

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Relationship

Phone

In case we cannot reach you, please provide the name and phone number of another person who can act on your behalf in an emergency:

Parent Signature

Sign above

Date

Medical Information

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