Childs Information
Childs Full Name
Childs DOB
Guardians Information
Guardians Full Name
Guardians Contact
Guardians Address
Emergency Information
Emergency Contact Name
Emergency Contact Number
Media Release:
I hereby grant permission for my child’s image and likeness to be used in any and all media, including but not limited to photographs, videos, and social media posts, for the purpose of promoting the youth sports organization.
Assumption of Risk and Release of Liability: I understand that participation in youth sports activities involves inherent risks, including but not limited to injury, illness, and even death. I voluntarily assume all risks associated with my child’s participation in these activities.
I hereby release and hold harmless ShockTown’s YES Community Program, Inc., its officers, directors, employees, volunteers, and agents from any and all liability, claims, demands, or causes of action whatsoever arising out of or related to my child’s participation in these activities, including any incidents or injuries that may occur.
Medical Treatment Authorization: In the event of an emergency, I authorize ShockTown’s YES Community Program, Inc. to seek medical treatment for my child, including but not limited to first aid, transportation to a medical facility, and administration of medication. I understand that every effort will be made to contact me prior to seeking medical care, but in the case of an emergency, immediate action may be taken.
Important Notice: ShockTown’s YES Community Program, Inc. is not a daycare, summer camp, or licensed child-care facility. The program is not licensed by the state and does not offer child-care services. The program provides structured sports, leadership, and safety education activities to youth participants.
Parents/guardians acknowledge that the program is not a substitute for daycare or after-school care services, and that the organization assumes no liability for child care or supervision outside of the scheduled program activities.
Guardian’s Acknowledgment and Signature:
By signing below, I acknowledge that I have read and understood this waiver and the important notice above, and that I agree to its terms. I further understand that my child’s participation is voluntary, and that I am fully aware of the risks associated with sports activities. I consent to my child’s participation in the program and agree to release ShockTown’s YES Community Program, Inc. from any liability as stated above.
Please Sign Below
SUBMISSION
