Youth Registration and Consent Form

Participant Information

Full Name

Date of Birth

Gender

Home Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone Number (Participant, if applicable)

Email Address (Participant, if applicable)

School/Grade Level

Parent/Guardian Information

Full Name

Relationship to Participant

Primary Phone Number

Secondary Phone Number

Email Address

Home Address (if different from participant)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Emergency Contact Information (Name, Relationship, Phone Number)

Medical Information

Health Insurance Provider and Policy Number

Primary Care Physician’s Name and Contact Information

Known Allergies (Food, Medication, Environmental)

Medical Conditions (e.g., asthma, diabetes, epilepsy)

Medications (Name, Dosage, Frequency)

Dietary Restrictions or Special Dietary Needs

Permission to Administer Over-the-Counter Medication (Yes/No)

Immunization Status

Consent for Emergency Medical Treatment (Yes/No)

Behavioral Information

Any Behavioral Concerns (e.g., ADHD, anxiety, etc.)

Strategies for Managing Behavioral Concerns (if applicable)

Swimming Ability

Swimming Proficiency

Permission to Use the Swimming Pool

Requirement for Supervision While Swimming

Transportation Information

Arrival/Departure Transportation Plans (Who will drop off/pick up the participant)

Permission for the Youth to Leave with Designated Individuals (List of approved individuals)

Photo/Video Release

Consent to Photograph/Video Record the Participant

Use of Photos/Videos (Promotional materials, website, social media, etc.)

Additional Information

Special Needs/Requests

Anything Else We Should Know About Your Child

Event Contact Information

Point of Contact for Questions (Name, Phone Number, Email)

Liability Waiver

Acknowledgment of Risks and Assumption of Liability

I, the undersigned, acknowledge that participation in the SOS Empowerment Convergence (the "Event") involves certain risks, including but not limited to physical activities, exposure to outdoor elements, and the use of facilities such as a swimming pool without a lifeguard on duty. By signing below, I voluntarily assume all risks associated with my/my child’s participation in the Event. I understand that these risks may result in injury, illness, or other unforeseen consequences.

Signature *

Release of Liability Agreement

In consideration of my/my child’s participation in the SOS Empowerment Convergence, I hereby release, waive, and discharge iAffirm Impact Foundation, its officers, directors, employees, volunteers, and affiliates (collectively referred to as the "Released Parties") from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, injury, or harm, including death, that may occur during or as a result of participation in the Event. I further agree to indemnify and hold harmless the Released Parties from any claims, demands, or actions arising out of or related to my/my child’s participation in the Event, including but not limited to any claims based on negligence.

Signature *

Code of Conduct Agreement

Acknowledgment of Expected Behavior

I, the undersigned, acknowledge that participation in the SOS Empowerment Convergence requires adherence to the following Code of Conduct: Respect for all participants, chaperones, and Event staff. Compliance with all Event rules and instructions provided by Event staff and chaperones. Responsible use of all facilities, including the swimming pool and shared spaces. No possession or use of prohibited substances, including drugs, alcohol, and tobacco. Maintenance of a positive and inclusive environment for all participants. I understand that failure to comply with the Code of Conduct may result in disciplinary action, including but not limited to removal from the Event.

Signature *

Consequences of Misbehavior

I, the undersigned, acknowledge and agree that any violation of the Code of Conduct or other misbehavior during the SOS Empowerment Convergence may result in one or more of the following consequences: Verbal warning from Event staff. Temporary removal from specific activities. Notification of parent/guardian and discussion of behavior. Immediate removal from the Event, with no refund or recourse. Reporting of serious incidents to appropriate authorities if necessary. I understand that the decision of Event organizers regarding consequences for misbehavior is final.

Signature *

Have you made any donations? *

How much ?

USD

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Last modified: September 18, 2024

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Liability Waiver

Acknowledgment of Risks and Assumption of Liability

Release of Liability Agreement

Code of Conduct Agreement

Acknowledgment of Expected Behavior

Consequences of Misbehavior

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