First Name 

Last Name 

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Age

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First Name

Last Name

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EMERGENCY CONTACT (1)

Full Name:

EMERGENCY CONTACT (1)

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EMERGENCY CONTACT (2)

Full Name:

EMERGENCY CONTACT (2)

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My Member...[Check ALL Boxes that APPLY]

(If your member takes Medication(s), has a Medical Plan of Action, or a Behavioral Plan of Action, or suffers from food and/or extreme seasonal allergies please provide the medical documentation to the Yeyo Office to be put on record.  If your member needs medication administered at any time during Yeyo, you will need to speak with the office administrators to complete a Permission to Administer Medication(s) Form)

(If your member takes Medication(s), has a Medical Plan of Action, or a Behavioral Plan of Action, or suffers from food and/or extreme seasonal allergies please provide the medical documentation to the Yeyo Office to be put on record.  If your member needs medication administered at any time during Yeyo, you will need to speak with the office administrators to complete a Permission to Administer Medication(s) Form)

Payment is due the MONDAY of each week.  Late payments will be assessed a $25 late fee.  You should receive your invoice by email at the beginning of the week, Sundays.  Payment is expected to be received  by Monday at the start of the week.  If payment is not received, you member will not be allowed to attend until payment is received.  

All RETURNED payments will result in a $55 RETURNED PAYMENT FEE. A second RETURNED FEE will result in $110 fee and Notice of Termination of Services due to excessive returned payments and resulting fees, unless ALL fees and member dues are paid in CASH in FULL! 

Agreement to Participate. All activities involve certain inherent risks.  I understand that violations of the rules and regulations, or misrepresentation of information on this form, may result in restriction, revocation, reduction or loss of program privileges without refund.

Waiver and Release: I hereby waive and release Yeyo Youth Club LLC, its officers, agents and employees, from and against any claims, suits, losses, or related causes of action for damages, including attorney’s fees and court costs, that may result from injury or death, accidental or otherwise, during, or arising from my child’s participation in a recreation program, including transportation to and from activities associated with the program, and any resulting illness and/or injury, and I agree to indemnify and hold harmless the Yeyo Youth Club from and against any and all such claims. I recognize that the recreational events or activities being entered into by my child can be dangerous to my child and I accept those dangers. I understand that if my child is injured, this waiver will be used against me and anyone else claiming damage in any legal action because of my child’s injury. I hereby acknowledge that I understand and am familiar with the nature of the activities in which my child will participate at this facility, and affirm that my child is in good health and that my child does not have a physical or emotional condition, past or present, of which I am aware, which would in any way affect my child’s ability to participate in recreation programs. I also understand that I should have health and accident insurance to cover injuries arising from participation in recreation programs. I also understand that I am responsible for immediate pick-up of my child upon completion of the program the child was registered in. 

 In case of emergency, I give my permission for emergency medical treatment of my child and for transportation to such treatment. 

 Photo/Video Consent: Photographs/videos may be taken during various programs. These photographs/videos may be used for future Yeyo Youth Club promotional material. Please indicate whether you will or will not grant permission to use your child’s photo for these purposes.