Amorak Youth Program Permission and Release of Liability Form

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Name of participant:

Age of participant:

Name of Parent/Guardian:

Parent signature- By typing your name and the date below you herby provide permission to use this information as your electronic signature

Address:

Phone #:

Name of program:

Location of program:

Dates of program:

Times of program:

I confirm that I am the parent or guardian of the program for the child or teen listed above. I give my permission for them to participate in this program. I understand that participation is at there own risk, that Amorak, Its directors or members, any collaborating organization, and the facilitator are not responsible for any illness or injury associated with the activity. The facilitator may arrange transportation during the program. If so, I give permission for my child to be transported to the program. Otherwise the parent/guardian is responsible for transportation.

Yes

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I give permission for photographs of my child to be used in promoting Amorak programs on its website, social media, in the newspaper or any other media source.

Yes

No.

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Please list severe allergies, physical limitations or medical conditions you feel we should know about:

Emergency Contact Name: (must be different from above)

Emergency Contact Phone #:

Option 1

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Submit

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