HFY program registration 2018-2019
Email address *
Name *
Date of birth *
MM
/
DD
/
YYYY
Sex *
Ethnicity *
Email *
Address *
Phone number *
Parent/Guardian Name *
Parent/Guardian Phone *
Parent/Guardian Name
Parent/Guardian Phone
Parent/Guardian email
Medical Condition/Allergies *
Prescriptions *
Name of Insurance Company *
Insurance ID #: *
Insurance card holder *
Emergency Contact *
Emergency Contact phone number *
I give permission for my son/daughter to participate in Hearts for Youth (HFY) programming. I acknowledge that participation in these programs involves risk and injury and I assume this risk. In consideration of this possibility, I hereby consent to emergency transportation and treatment necessary in the event of illness or injury. I hereby accept responsibility for the payment of any emergency transportation or treatment. This program involves physical activity and I further acknowledge that my child is fully capable of performing the activities required. I agree to hold HFY and personnel harmless from and against any and all liability, loss, damages, claims, or actions (including costs and attorney fees) for bodily injury or property damage, to the extent permitted by law. I also hereby consent to and authorize the use and reproduction by HFY of any photographs taken of my child for purposes of advertisement (i.e. publications, website, news etc) without any compensation to me or my child. All negative, positives and digital images shall constitute the property of HFY solely and completely. If you DO NOT consent, please send us a letter in writing. By typing my name below, I consent to submitting this form and my authorization electronically. *
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