Teen Event Consent Form and Liability Waver
Name *
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Today's Date *
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Parents' Name *
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Address *
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Phone Number
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Confirm Phone Number
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Email
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Electronic Signature
By electronically signing this form, you grant permission for your child listed on this form to participate in the UP Center's teen event December 8, 2018 that will be held in a location outside of the UP Center of Champaign County office. By signing this agreement, you acknowledge that PHOTOGRAPHS MAY BE TAKEN AT THIS EVENT AND SHARED via social media. This activity will take place under the guidance and direction of UP Center employees and/or volunteers from the community that have undergone background checks at Arcadia-A Lumen Cafe.

As a parent and / or guardian, I remain legally responsible for any personal actions taken by the above named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns to hold harmless and defend the UP Center of Champaign County and its officers, directors, employees, and agent, chaperons, or representatives associated with the event, from any claim arising from or in connections with my child attending the event in connection with any illness or injury (including death) or cost of medical treatment in connection therewith.

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Parent's Signature
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Today's Date
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