2025-2026 PVYC Registration, Waiver and Release Agreement
I hereby give my permission for my child to participate in Penns Valley Youth Center Activities (After School Programs, Workshops, Field Trips, etc.) with the Penns Valley Youth Center (PVYC) Staff and Volunteers, as well as, approved subcontracted professionals.  
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Student's First and Last Name *
Student's Phone (if applicable) *
Opt into SMS communication *
Student's Email (if applicable) *
Parent/ Guardian Name *
Phone *
Opt into SMS communication *
Email (regularly checked) *
Parent/Guardian Name
Phone 
Opt into SMS communication
Clear selection
Second email
Third email
Home Address/ City/ State/ Zip *
Mailing Address/ City/ State/ Zip *
Grade *
School *
How will your student arrive to the PVYC Afterschool Program (Old Gregg School)? *
Required
Who has permission to pick up student? 
(please include all individuals and their relationship to your child who are allowed to pick up your student)
 *
Child's Date of Birth *
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T-Shirt Size *
Required
CONSENT TO PARTICIPATE
I, consent to my child's participation in all activities held at the PVYC After School program and Youth Group. It is understood that there are certain risks that may result in damages or injuries during my child's participation in these activities.  
I certify that my child is fully capable of participating in all activities and has no physical or mental disabilities that would restrict his/her full participation.
 *
Required
RISK
I accept and assume all risks of injury or harm on behalf of my child associated with or resulting from participation in such activities while at the PVYC either on location at the Old Gregg School or at a permitted off site location.
 *
Required
LIABILITY
I, for myself, my child, my child's heirs, personal representatives, and assigns, hereby release, discharge and agree to hold harmless the PVYC Staff and Volunteers as well as any approved subcontractor and the Penns Valley Youth Center from all liability, loss, claims, demands and possible causes of action that may accrue from any loss, damage or injury to person or property in any way resulting from or arising in connection with or related to my child's participation in the Youth Center. It is fully understood that this means that the PVYC Staff and Volunteers as well as any approved subcontractor cannot be sued if any personal injury is suffered by my child during the Youth Center sponsored activities or if any property is damaged, lost, or stolen while my child is participating in PVYC Activities, except to the extent that such injury to person and/ or loss of or damage to property results from a grossly negligent, international or malicious action, failure to act or omission by PVYC Staff and Volunteers as well as any approved subcontractor.
 *
Required
TRANSPORTATION
I give my express permission for my child to be transported to an off site event in PVYC vans, driven by approved PVYC staff members, if applicable, to an offsite event. I also give permission for my student to be transported to an event by a paid busing company in the case of an offsite event. In the event that extra vehicles are needed, I give permission for my child to be transported in a personal staff vehicle with two adults present.
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Required
INDEMNITY
Furthermore, I, on behalf of my child, as well as for myself hereby undertake to indemnify the PVYC, its Staff and Volunteers, as well as any approved subcontractor against any and all liability, loss or damage for which the PVYC Staff and Volunteers as well as any approved subcontractor may be found liable as a result of claims, demands or judgments against them all or any of them arising from any act or failure to act on the part of my child during the course of the PVYC Activities. It is fully understood that this means that if my child causes injury to another person or damages another person's property while participating in PVYC Activities, and PVYC Staff and Volunteers as well as any approved subcontractor have to pay an amount to that person, the indemnities hereunder can recover the amount paid from the Parent/Guardian.
 *
Required
MEDICAL RELEASE
While the PVYC Staff and Volunteers will make every reasonable effort under the circumstances to contact the Parent/ Guardian in the event my child faces a medical emergency, Parent/ Guardian hereby authorizes each of the adult PVYC Staff and Volunteers to secure medical treatment by medical professionals, at my expense, for any injury or illness suffered by my child, as may be necessary to stabilize my child and to minimize additional injury or affects of illness during whatever time on the PVYC Activities it takes to contact Parent/ Guardian for further instructions.
 *
Required
In Case of Emergency, Please Contact:
1. Name *
Phone *
Relationship to Student *
2. Name *
Phone *
Relationship to student *
Medical Information
Do we have your permission to administer First Aid, if necessary? *
Required
Physician *
Phone *
Medical Insurance Company *
Policy # *
Member's Name *
Allergies/ Medications *
Other
Any Legal obligations or Custody situations we should be aware of? *
Discipline
I understand that attendance at the Penns Valley Youth Center and its sponsored events is a privilege, and not a right conferred to each student. As such, I understand and assume the expenses of any property damage caused by my child. Should it be necessary that my child be removed from the premises due to inaction or failure to abide by the rules of the PVYC and conduct unbecoming of good naturedness and generally accepted social behaviors, I will agree to such discipline as required. In addition, should it be necessary that my child be returned home due to disciplinary action (when on trips or outside of the PVYC premises), I will be contacted by the appropriate staff/leaders and will be responsible to pick my student up and assume any and all costs of transport. Regarding cell phone use, any student that uses their phone for bullying, taking or posting inappropriate content will have their phone confiscated for the remaining time of programming and parent will be contacted by staff/volunteer.
 *
Required
Nutrition
On occasion, the Penns Valley Youth Center offers snacks and meals at no cost to our students. While every effort is taken to accommodate special dietary needs, it is often difficult to accommodate each child's preferences and is difficult to ascertain special dietary restrictions without prior notification. Please list any special dietary restrictions below for your shild, including but not limited to, food allergies, dietary restrictions such as gluten, wheat, organic, chemical-free, lactose intolerance, etc. and any particular foods that your child should not partake of.
 *
Required
Photo Release
Please select your preference in allowing the use of your student's image and likeness to be used in various media such as flyers, websites, email, etc. for public display and to promote the events, benefits and programs of the Penns Valley Youth Center.
Photo Release Permission *
Required
I HEREBY DECLARE THAT I HAVE READ THIS WAIVER AND RELEASE AGREEMENT AND ACCEPT THE SAME IN FULL ON BEHALF OF MYSELF, MY SPOUSE, MY CHILD, MY CHILD'S HEIRS, PERSONAL REPRESENTATIVES AND ASSIGNS.
This Agreement is made as of this day: *
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Signature of Parent/Guardian *
Please feel free to offer additional information or background on your student in the space below to help us better understand and promote appropriate programs for your student.
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