Child & Youth Program Registration Form

I. Event Information (from flyer)

Name of Event: ______Date of Event: ______

Place of Event: ______

II. Military Sponsor’s Information

Military Sponsor’s Name: ______

Relationship to child(ren): ______

Service (Please Check):

Massachusetts Army National Guard Massachusetts Air National Guard

Unit ______Unit ______

III. Participant(s) Information:

Name ______Date of Birth ______Gender ______

Parent /Guardian Name ______

E-mail ______

Phone numbers where parent/guardian can be reached in case of emergency DURING THE EVENT:

Home/Work:______Cell:______

Allergies, concerns or other medical/behavioral information you feel we should know (please specify child):

______

Name(s) of adult(s) authorized to pick up participant(s). ID’s will be checked and only persons listed below will be allowed to pick up participant(s).

Name Relation to Child

______
______

My child(ren) has/have permission to attend this MA National Guard Child and Youth Program Event.

______

Parent/Guardian’s signature Date

Massachusetts Child and Youth Program PHONE: 888-301-3103 EXT 7290 or 7952 FAX: 508-233-7232 EMAIL:

Massachusetts National Guard Child and Youth Program

14 Minuteman Lane

Wellesley, MA 02481

508-233-7290

PARENT’S CONSENT FOR MINOR CHILD TO PARTICIPATE

AND

HOLD HARMLESS AGREEMENT AND RELEASE

I, (Print Name of Minor’s Parent or Legal Guardian) ______state that

(Print Minor’s Legal Name) ______(hereafter referred to as “the minor”)

Event/Location ______

hereby consent to the minor’s attendance and participation in the event listed above, with the Massachusetts National Guard Child and Youth Program. I understand that participation in this program or sanctioned event is strictly VOLUNTARY. I understand that the event or program involves activities which could result in injury to the minor’s person or damage to the minor’s property, and that by participating, I voluntarily accept and assume the risk of injury to the minor or damage to the minor’s property and consent the minor’s participation in the event or program.

I give permission for the minor listed on this form to attend and participate in all activities except as may be noted on physical/medical forms. The information on these forms is true and correct to the best of my knowledge. In case of sudden illness or an accident to my child requiring immediate treatment or surgery I authorize the primary staff or medical staff to take such action as deemed appropriate to protect the health and physical well-being of my child.

In exchange for allowing the minor to participate in this event or program, the minor by and through the undersigned, agrees to release from liability, indemnify, and hold harmless the Massachusetts National Guard, the State of Massachusetts, the United States of America, their agents, servants, and/or employees and contractors from any and all claims, demands, losses, expenses, actions or causes of action to the minor’s person or damage to the minor’s property which arises out of, or occurs during, or as a consequence of, the minor’s participation in the event or program, whether or not such injury or damage may have been caused, in whole or in part, by any negligence or want of care on the part of the Massachusetts National Guard, the State of Massachusetts, the United States of America, their agents, servants, and/or employees and contractors. This Hold Harmless Agreement and Release shall be binding upon the minor, the parent(s), or guardian(s), any successors in interest, and/or any person(s) suing on the minor’s behalf.

I understand that this document is complete unto itself and that any oral promises or representations made to them concerning this document and/or its terms are not binding upon the Massachusetts National Guard, the State of Massachusetts, the United States of America, their agents, servants, and/or employees and contractors.

PHOTO RELEASE

I understand that the Massachusetts National Guard develops photographic and multimedia materials, which will represent National Guard Families. I grant the Massachusetts National Guard Family Program and its staff and associated entities, the right to use and reuse, said photographs for the purposes of promotional and advertising uses, and other trade purposes. I acknowledge and agree that I will not receive any compensation for such photographs or their use.

I grant my permission for such use as described above.

Please initial one:

______I am over the age of 18 years and I have read the foregoing and fully and completely understand the contents.

______I represent that the person in the photographs is a minor and that I am the parent of the minor and that I have read the foregoing and fully and completely understand the contents.

PARENT OR LEGAL GUARDIAN MUST SIGN BELOW:

I, the undersigned state that I am the parent/legal guardian of the minor whose name appears above. I understand that the above terms and conditions apply to said minor and to myself. I further understand that that said minor cannot participate under ANY circumstances in the above specified event or program without parental consent and that the minor will not be allowed to participate without entering into this agreement. This document is binding upon myself, the said minor, and any person suing on behalf of said minor.

Minor’s Name (PRINT) ______Birth Date of Minor ______

PARENT/GUARDIAN LEGAL NAME (PRINT) ______

PARENT/GUARDIAN LEGAL NAME (SIGN) ______

Address ______City______

State______Zip Code______Phone ______

Executed at ______, Massachusetts on ______(date).