Strengthening Families Teen Participant Registration Form (for July 1, 2018 to June 30, 2019)
The United Way of Delaware County's Strengthening Families Community Teen Room, designed by teens, provides a unique, ever-changing combination of events, activities, hang time, and quiet coves in a safe space. Teen Community Room and STEAM (Science, Technology, Engineering, Arts, and Math) programming is for students grades six to eighth who reside in Delaware County.

In order for your MIDDLE SCHOOL STUDENT to participate in ANY Strengthening Families programming, we need parent/guardian consent and involvement in providing information to help your middle school student have a productive and safe experience.

Student Participant First Name *
Your answer
Name of School Participant Currently Attends *
Your answer
Participant's Grade *
Student Participant Last Name *
Your answer
Participant's Date of Birth *
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Participant's Primary Address *
Your answer
Participants' Home Phone with area code *
Your answer
Parent Email *
Your answer
Parent/Guardian Full Name *
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian's Cell Phone (home phone is cell is unavailable) *
Your answer
Parent/Guardian's Work Phone
Your answer
Emergency Contact's if Parent/Guardian is unable to be reached.
Your answer
Emergency Contact's relation to student participant
Your answer
Emergency Contact's Cell Phone (or home phone if cell is unavailable)
Your answer
Emergency Contact's Work Phone
Your answer
PARENTAL CONSENT: The undersigned does hereby give permission for (insert student's name), *
Your answer
to attend and participate in any United Way of Delaware County activities and programming during the period of (insert today's date, include month, day, and year) to June 30, 2019. *
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MEDICAL TREATMENT AUTHORIZATION: I hereby give my consent to have a teacher, coach, instructor, authorized volunteer, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the Participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the Participant to a medical treatment facility should an individual listed above consider it to be warranted. *
LIABILITY RELEASE: In consideration of United Way of Delaware County allowing the Participant to participate in child/youth activities, I, the undersigned, do hereby release, forever discharge and agree to hold harmless United Way of Delaware County, its sponsors, affiliated organizations, and employees, authorized volunteers, and associated personnel of these organizations, and Delaware City School District, from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities. I, the parent or legal guardian of the Participant, hereby grant my permission for the Participant to participate fully in child/youth activities. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said United Way of Delaware County, its sponsors, affiliated organizations, and employees, authorized volunteers, and associated personnel of these organizations, and Delaware City School District, for any liability sustained by said organization as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto. *
EARLY RETURN HOME POLICY: The undersigned is aware that certain programs and activities are based on a “first come/first served” basis depending on the capacity of the room and/or number of program participants. Should it be necessary for the Participant to return home due to medical reasons, disciplinary action, weather conditions, or if programs or activities have reached their maximum capacity, the undersigned shall assume all transportation costs and responsibility. *
My child is to follow these arrangements after the programming at Strengthening Families: Please check the appropriate box. *
Required
If you placed a check mark regarding someone other than yourself picking up your child, please list the person's name, relationship to the child and their phone number. If you did not place a check mark on someone else picking up your child, please write "N/A" in this box. *
Your answer
List Student's Primary Care Physician *
Your answer
Primary Care Physician's Phone Number *
Your answer
List Medical Insurance Company student is listed on: *
Your answer
Medical Insurance Company's Phone Number *
Your answer
Medical Insurance Policy/Group ID# *
Your answer
Policy Holder's Name *
Your answer
Medical Conditions - List any medical conditions student has:
Your answer
List any of the student's allergies, the severity, and the type of reaction:
Your answer
I CERTIFY THAT I AM the PARENT/GUARDIAN OF THE STUDENT PARTICIPANT listed in this document AND THAT I HAVE READ, FULLY UNDERSTAND, AND AGREE TO THE TERMS OF THIS AGREEMENT, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE. *
I agree to the terms on (insert today's date). *
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I understand that pictures and/or videos of my child may be taken during Strengthening Families programs and hereby agree and consent to the use of these pictures/videos by United Way of Delaware County or its partner agencies for promotional or any other purpose. *
For up to date information on Middle School Opportunities go to www.delawarecountyfamilies.org or follow us on Facebook at Strengthening Families -United Way of Delaware County.
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