Pre-Teen Registration & Permission Form for Apex
This form should be filled out by 6th-8th graders & a parent/guardian.
I acknowledge that the participation of my child (listed below) in the Apex Event is voluntary and may result in personal injury or property damage. I understand and assume, on behalf of my child, all risks relating to participation in this event and agree that Temple Israel of Natick and its employees, directors, officers, agents, representatives, independent contractors, licensees and sponsors (collectively, the “Releasees”) shall not be responsible for any personal injury, property damage and/or other loss suffered as a result of my child's participation in any of the individual activities (an “Injury”). I understand by signing below on behalf of my child, and in consideration of being permitted to participate in the volunteer activities, I forever release each of the Releasees from any and all liability arising from an Injury. *
Child participating in APEX event *
Type your pre-teen's first and last name
Your answer
*
Type your name to sign
Your answer
I hereby empower Temple Israel of Natick staff to act for me in accordance with their best judgment in case of emergency. I hereby authorize the physician selected by a Temple Israel of Natick staff person to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child named above. *
I understand that my child's picture may be taken at this event, and that it may appear on websites, social media or in a brochure promoting the Metrowest Pre-Teen Engagement Initiative. *
Participant’s Last Name *
Your answer
Participant’s First Name *
Your answer
Home Address *
Street, Town, State and Zip Code
Your answer
Participant email address *
Your answer
Birthdate *
Your answer
What grade is your child in? *
School Name *
Your answer
School Type *
Please let us know which institutions you are affiliated with. *
Required
Participant's cell phone number
Your answer
Participant's home number
Your answer
Parent/Guardian 1 Name *
Your answer
Parent/Guardian 1 cell phone number *
Your answer
Parent/Guardian 2 name
Your answer
Parent/Guardian 2 cell phone number
Your answer
Parent email addresses
Separate multiple addresses with a comma
Your answer
Emergency Contact (if Parent/Guardian 1 & 2 are unreachable) *
Contact name & relationship to teen
Your answer
Emergency Contact Phone Number *
Your answer
Participant's Primary Care Physician's Name
Your answer
Participant's Primary Care Physician's Phone Number
Your answer
Participant's Insurance Company
Your answer
Are there any special medical or dietary concerns or limitations to your child’s full participation in our youth program? (All information is completely confidential.)
Your answer
Signature of Parent or Guardian *
Type your name below to sign
Your answer
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