PRO Teen Registration and Permission Form

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At PRO we offer a number of activities and opportunities for our youth to have FUN!

Safety is a high priority of ours so please fill out the below form and submit prior to your youth visiting the facility.

If you have any questions: Contact Robin Bruck at 603-235-0973 OR ROBIN.BRUCK@PROYOU.ORG

電子郵件 *

(Youth) First Name *

(Youth) Last Name *

(Youth) Date of Birth *

YYYY

(Youth) Phone number *

Current School *

(Youth) Street Address *

(Youth) Town *

(Youth) State *

(Youth) Zip Code *

Parent/Guardian first name *

Parent/Guardian last name *

Parent/Guardian email address *

Parent/Guardian address (if different than above) *

Is parent/guardian above the emergency contact for the youth? *

Yes

If not, please fill in the next question

Emergency Contact name (if different than parent/guardian)

Emergency Contact address

Emergency Contact email address

Emergency Contact best phone number

Emergency Contact relationship with youth

Does your teen have any allergies (food, environmental, etc)? Please provide details. *

From your point of view, what are the most important issues and difficulties that your teen faces? *

What are some things you would like us to know about your teen? *

Does your teen have any dietary restrictions? *

What are some favorite foods of your teen? *

In order to deliver our Teen program with no charge we are always looking for people or businesses to sponsor healthy food for this group. Do you have any interest in sponsoring this (usually the cost is about $100 per event)? *

Yes

Permissions-please check to confirm permissions: *

In the event of an emergency PRO will attempt to contact me prior to any medical treatment. I give permission for my child to receive emergency medical treatment, including the use of anesthesia, as recommended by medical practitioners.

I give permission for my child to be transported by PRO staff/volunteers to/from activities and or home as needed.

In case my child is injured PRO has permission to treat my child with Aspirin, Ibuprofen, Tylenol, Ice Pack, Triple Antibiotic, Band Aid etc.

I give permission for the use of various media representations of my child, including photo, audio, video and written for education, outreach, and recognition purposes.

I give my child permission to eat the food and meals provided at PRO .

I give my child permission to leave with a friend and/or family member.

In consideration for the permission granted by the Personal Responsibility Organization (PRO) for above Minor to participate in this Event, on my behalf and on behalf of the Minor, and each of my and the Minor’s heirs, executors, and administrators, I hereby waive and release any and all causes of action, claims, suits, damages, and judgments, in any form whatsoever, arising from or by reason of any and all known or unknown, foreseen or unforeseen bodily or personal injuries (including death) or property damage, resulting from the Minor’s participation in the Event and related activities, against Personal Responsibility Organization (PRO) and their employees, administrators, trustees, volunteers, and agents.

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