Sign Him Up - Resurgence Leadership Foundation

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Please complete All three forms below

Protege Authorization Form

"*" indicates required fields

Liability & Authorization Form

"*" indicates required fields

Participant's Full Name*

DOB Month*

Please enter a number from 1 to 12.

Day*

Please enter a number from 1 to 31.

Year*

Please enter a number from 2000 to 2050.

Address*

City*

State*

Zip Code*

Participant's Cell Number

Parent/Guardian Information

Parent/Guardian's Full Name*

Relationship to Participant*

Parent/Guardian's Cell Number*

Parent/Guardian's Work Number

Parent/Guardian's Email*

Emergency Contact Information

Full Name*

Relationship to Participant*

Cell Number*

Work Number

Medical Information

Primary Physician Name

Work Number

Allergies (including medications student can NOT take)

Special Health Concerns

Medical Care Information

Medical Insurance Company:*

Policy/Group Number:*

Participant I.D. Number:*

Medical Insurer Phone Number:*

Medical Care Authorization

As the parent(s) or guardian adult, I/we give permission for Young Commanders Leadership Program, and its agents, staff, and volunteers to obtain emergency medical care for my/our child, and I/we authorize health care providers to render such care as may be necessary. It is understood that reasonable efforts will be made to contact me/us prior to obtaining such care, but I/we authorize such care whether I/we are contacted or not, and I/we agree to be financially responsible for such care.

Signature of Parent/Guardian*

Participation in Activities Authorization

1. As the parent(s) or guardian adult, I/we give permission for my son/grandson to participate in Young Commanders Leadership Program on site or elsewhere.

Participant's Name*

Initial Here*

2. I acknowledge that Young Commanders Leadership Program is an activity and such activity is subject to mishap and even injury to participants, including the potential for permanent paralysis and death. I understand and acknowledge that activities have inherent dangers that no amount of care, caution, instruction or expertise can eliminate and I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISK OF DEATH OR PERSONAL INJURY SUSTAINED WHILE PARTICIPATING IN ALL TOUR ACTIVITIES WHETHER OR NOT CAUSED BY THE NEGLIGENCE OF THE RELEASED PARTIES.

Initial Here*

3. I take full responsibility for, RELEASE AND HOLD HARMLESS Young Commanders Leadership Program, their owners, officers, elected officials, agents and employees from any and all liability, claims, demands or causes of action that I may hereafter have for injuries or damages arising out of my son/grandson participation in Young Commanders Leadership Program, mentor/enrichment activities, included, but not limited to, losses CAUSED BY THE NEGLIGENCE OF THE RELEASED PARTIES.

Initial Here*

4. I further agree that I WILL NOT SUE OR MAKE CLAIM against the Released parties for damages or other losses sustained as a result of any injury, or death, sustained from my participation in any and all mentor/enrichment activities. I also agree to INDEMNIFY AND HOLD THE RELEASED PARTIES HARMLESS from all claims, judgments and costs including attorney's fees, incurred in connection with any action brought as a result of participation in Young Commanders Leadership Program, mentor/enrichment activities by any of the undersigned.

Initial Here*

5. I hereby expressly recognize that this Release of Liability, Waiver of Legal Rights, and Assumption of Risk is a contract pursuant to which I have released any and all claims against the Released Parties resulting from any injury, or death, sustained from participation in Young Commanders Leadership Program, mentor/enrichment activities including any claims for negligence of the Released Parties.

Initial Here*

6. I further represent that I am at least 18 years of age (if younger, accompanied by a parent, legal guardian who accepts responsibility on their behalf), I waive and release any and all legal rights that may accrue to me as the result of any injury I may suffer while engaging in Young Commanders Leadership Program, mentor/enrichment activities.

Initial Here*

Photographs and Video Consent

I hereby waive any right to inspect or approve the use of the still images or video recordings or of any written copy. I further waive all moral rights. I also waive any right to royalties or other compensation arising from or related to the use of the still images, video recordings, or materials. I hereby release, defend, indemnify and hold harmless the producers from and against any claims, damages or liability arising from or related to the use of the images, recordings or materials, including but not limited to claims of defamation, invasion of privacy, or rights of publicity or copyright infringement, or any misuse, distortion, blurring, alteration, optical illusion or use in composite form that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. I am 18 years of age or older and I am competent to contract in my own name. I have read this document before signing below, and I fully understand the contents, meaning and impact of this consent, waiver, indemnity and release.

Initial Here*

Vehical Travel Permission

I/we give permission for my/our child to travel in a privately owned or a Young Commanders Leadership Program owned vehicle operated and occupied by only one (1) adult.

Initial Here*

I HAVE READ THIS RELEASE OF LIABILITY, WAIVER OF LEGAL RIGHTS AND ASSUMPTION OF RISK AND FULLY UNDERSTAND ITS CONTENTS. I SIGN IT OF MY OWN FREE WILL.

On this the day,*

Signature of Parent/Guardian*

Name of Child Participant*

Number

Field Trip Form

"*" indicates required fields

From time to time during the year, Young Commanders Leadership Program (YCLP) will plan experiential learning outreach trips off the meeting premises to enhance your child’s educational and social development. All trips will be chaperoned by YCLP directors, staff members/volunteers/mentors and YCLP parents/guardians. We expect that we will give you several days’ notice of most trips but in some instances, such advanced notice may not be possible. We ask, therefore, that you sign and return this YCLP Permission slip so that your son/grandson has permission to go on these trips. I understand and acknowledge that some trips may require travel on public conveyances and that my son/grandson will be on premises not controlled by YCLP. Thus I acknowledge that YCLP cannot be held responsible for any injuries to my son/grandson. I, on behalf of my spouse or other guardian of my child and on behalf of my child, so waive and release YCLP, its agents, employees, officers, and directors for any claims and damages which may arise during his travel and participation of these trips and I give my son/grandson permission to leave the meeting premises with the YCLP group chaperoned by adults.

Participant's Full Name*

Parent/Guardian's Full Name*

Parent/Guardian's Cell Number*

Parent/Guardian's Email*

Address

City*

State*

Zip*

Date*

Type tH@nk$*

Sign

Him Up Today

Please complete All three forms below

Protege Authorization Form

Parent/Guardian Information

Emergency Notification

Liability & Authorization Form

Parent/Guardian Information

Emergency Contact Information

Medical Information

Medical Care Information

Medical Care Authorization

Participation in Activities Authorization

Photographs and Video Consent

Vehical Travel Permission

Field Trip Form

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