JAE Open Gym Sign Up
Sign up to participate in North Shore Youth Council's JAE Open Gym Night!
Admission per child: $5
Enter Child's First Name *
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Enter Child's Last Name *
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If they go by a nickname, you may enter it here:
*Optional
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Enter Child's Gender: *
Child's Age: *
List any of the Child's Medical Issues/Allergies: *
If there is none, enter "None"
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Child's School: *
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Enter Your Full Name: *
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What is your relation to the child? *
Enter Your Phone Number: *
Preferably in format (777)-777-7777
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Enter Your Email Address: *
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Enter Your Address: *
Ex: 123 Lollipop Lane, Candy-Land Arkansas 11111
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Enter an Emergency Contact Number: *
Preferably in format (777)-777-7777
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Enter Name for Emergency Contact *
Enter first and last name:
Your answer
What is the Emergency Contact's relation to the Child? *
Enter a Second Emergency Contact Number: *
Preferably in format (777)-777-7777
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Enter Name for Second Emergency Contact: *
Enter first and last name:
Your answer
What is the Secondary Emergency Contact's relation to the Child? *
Submission Agreement
By submitting this, I verify that the child listed above has my permission to participate in all activities offered. If attempts to contact me at the above listed phone #’s are unsuccessful, I authorize and give my consent for any emergency medical, surgical or dental treatment for my child (listed above) anywhere/anytime should it be deemed advisable by a qualified medical Doctor or Dentist, and the prompt attention/treatment in an emergency. I authorize the North Shore Youth Council to take all necessary steps to insure my child’s health & safety in case of an emergency and to administer any needed medications. In case of accident or injury I will not hold the North Shore Youth Council, or its employees or volunteers responsible. I understand and assume all risks that may occur during my child’s participation in these programs. I understand that should any injury occur to my child at the program, I will be responsible for all medical treatment and other costs through my medical insurance policy and/or personal finances.
Electronic Signature: *
This will take place of your handwritten signature, and is used to verify your agreement to all terms, conditions, and agreements listed on this form.
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