Y.E.S I Can Summer 2018 Emergency/Release Form
Y.E.S I Can Emergency and Legal Form
Y.E.S I Can Summer College Prep form, Parent/ Guardian must complete the following form. The program will run August 6th - August 25th.

For the Y.E.S I can application, please use this link: https://goo.gl/forms/UQq6ecEdw0Do6Y9l1


For more information about the Y.E.S I can Program and AMBYESE, please visit our website www.ambyese.org

Email address *
In case of emergency, please notify (First Name, Last Name) *
Your answer
Relationship to Student *
Your answer
Emergency Contact Address (Street Name, City, State, Zip *
Your answer
Emergency Contact Home Phone Number *
Your answer
Emergency Contact Cell Phone Number *
Your answer
Does the student have any allergies *
If yes, please list allergies.
Your answer
NOTE: Y.E.S I Can Retains the right to suspend any student who is not meeting his/her commitment. Sign and Date. Include applicant Full name and Initial in acknowledgement (Ex: Jane Doe, J.D. 1/23/2018) *
Your answer
Release and Indemnity Agreement for and in consideration of the participation of my child-- Include Child name *
Your answer
in the Y.E.S I can summer Program, the undersigned, individually, and as the parents and/or guardian and next best friend of my minor child, do hereby release and forever discharge the said Y.E.S I CAN, AMBYESE, Wendell Johnson, including each business/organizations or individual's predecessors, successors, assigns, employees, agents and their insurance carriers and all other persons, firms or entities, from any and all actions, causes of action, claims and demands for any damage, loss or injury, which may hereafter be suffered by my minor child, for any reason that is not the result of gross negligence on their part as a result of transportation to and participation in the Y.E.S I CAN program. Sign and Date (Ex Jane Doe, 1/23/2018) *
Your answer
IT IS FURTHER AGREED that the student will fully participate in the entire three-week program and that in consideration of the participation recited herein, the undersigned, as parents and/or guardian of my minor child, do agree to hold harmless, indemnify and defend, at my sole expense, including all litigation expenses such as attorney fees, court costs and the like, the parties released herein from any claims or suits which may or could be urged in the future, at any time, by the said minor child, or anyone claiming by, through or for him/her, because of any damage, loss, or injury suffered as a result of transportation to or participation in the Y.E.S I CAN program. Permission is also hereby granted for the photographing and release of my child's academic records and use for the Y.E.S I CAN program. All students enrolled in the program are expected to remain on the student roster until the student graduates from high school, providing they meet the program's requirements. This document was read, agreed to, and signed by the undersigned, in my respective capacity as___________________________ defined in this document on this _______________________ day of ______________________________ 20____. Please use space provided to complete above blanks (ex parent.... 23rd .... January, 2018) *
Your answer
IT IS LASTLY AGREED that the student will fully participate in the entire three-week program and that in consideration of the participation recited herein, the undersigned, as parents and/or guardian of my minor child, do agree to fully reimburse AMBYESE for all estimated costs if after acceptance the student fails to participate in the summer program. Provide signature in space provided (ex. Jane Doe) *
Your answer
Parent/ Guardian Signature (example signed Jane Doe) *
Your answer
Parent/Guardian Email *
Your answer
Guidance Counselor Email *
Your answer
SWORN TO AND SUBSCRIBED ON THIS ______________ DAY OF _____________, 20____WITNESS SIGNATURE________________________ Please fill in the blanks in the space provided (ex. 23rd..... January, 2018) Signed George Doe *
Your answer
A copy of your responses will be emailed to the address you provided.
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