YOUTH SERVE

Student Name *

First Name

Last Name

Parent/Guardian Name *

Emergency Contact

First Name

Last Name

Parent/Guardian Phone *

To use as emergency contact

(###)

###

####

I, as the parent/guardian, give my child who is registered for UABC Youth Serve, permission to participate in the event. I will not hold the UABC staff or volunteers responsible for accidents that may occur. *

I Do

I Do Not

I also authorize medical assistance and/or surgical treatment in the event of an emergency by a physician chosen by the leaders of the event. (We will make every effort to contact you if any emergency occurs). I understand that I am responsible for any cost of medical treatment my child may need. *

I Do

I Do Not