Participant Medical Form and Liability Release

Participant Information

Participant Name(Required)

First Last

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/ Emergency Contact

Parent/ Guardian Name(Required)

First Last

Parent/Guardian Cell Phone(Required)

Other Phone Number

Parent/Guardian Email Address(Required)

Second Parent/ Guardian Name

First Last

Second Parent/Guardian Cell Phone

Other Phone Number

Second Parent/Guardian Email Address

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Physical Therapist Name(Required)

First Last

Emergency Care Consent

In case of emergency, take the following action:(Required)

I hereby grant my consent to transfer my child to the nearest hospital or clinic and call the emergency contact listed on this form.

I do not give consent for emergency medical treatment of my child. In the event of illness or injury requiring medical intervention, take no action and call the emergency contact listed on this form.

Release of Liability

The undersigned understands, recognizes, and assumes the inherent risks associated with Youth Challenge’s athletic and recreation programs, including the risks associated with transporting participants and volunteers to programs and related activities. In consideration for being permitted to participate as either a participant or volunteer in the recreational programming of Youth Challenge, the undersigned releases, waives, discharges and covenants not to sue Youth Challenge, its trustees, employees, agents, other volunteers, other participants, and if applicable, sponsoring agencies, advertisers, and owners or lessors of premises that host recreational programs from any and all liability arising out of any injury or illness including, but not limited to, MRSA, influenza or COVID-19 resulting from my child’s participation.

In the event there is a need for emergency medical treatment for the minor participant or volunteer and the undersigned cannot be reached, the undersigned consents to and assumes the financial responsibility for such emergency treatment.

The undersigned grants permission to Youth Challenge and any donor, sponsor, or other entity or person for the taking of pictures and videos and the release of general information about the minor participant or volunteers for use in media outlets or publications whatsoever, without there being any liability on the part of Youth Challenge, its employees, trustees, or agents.

Parent Signature (or participant if over 18)

By electronically signing below, I certify that the information included herein is complete and accurate to the best of my knowledge

Parent/ Guardian First Name Last Name

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Participant Medical Form and Liability Release