NCYC Registration | Northwestern Communi

Register for the 2024-25 year at the Center!

NORTHWESTERN COMMUNITY YOUTH CENTER MEDICAL RELEASE FORM/PERMISSION SLIP

Center's Phone:

(814) 756-5087

Center's Email Address

nwcycdirector@gmail.com

Teen's First Name

Teen's Last Name

Teen's Email

Teen's Street Address, State, Zip

Teen's Phone

Teen's Birthday

Teen's Insurance Company Name & Address

Policy number

Any allergies or special conditions for your child?

Any physical handicaps or restricted activities?

Parent/Guardian First Name

Parent/ Guardian Email

Parent/ Guardian Last Name

Parent/Guardian Cell Phone

In case of a medical emergency, I hereby give permission to the physician selected by the leader in charge to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child, as named on this form. I certify that my child is in good physical condition and is able to participate in the entire program, other than any activities listed as restricted above.

I give Northwestern Community Youth Center permission for my child to participate in any events for the 2024-2025 school year and throughout the 2025 summer. I further agree to hold Northwestern Community Youth Center and its agents harmless and to indemnify them against all losses, liabilities, claims, or expenses including fines, penalties, and attorney’s fees due to injury or alleged injury to my child incurred in connection with the operation of the conference, and transportation thereto. I also assume responsibility for any damages to the facility he/she is assigned to that were caused by him/her.

I give Northwestern Community Youth Center permission to use pictures and videos of my child in multi-media. I understand that NCYC will use discretion and sound judgment in taking pictures and videos of my child in the above-stated manner.

As the above-listed minor’s parent or guardian, I have read and agree to all of the above.

Parent/ Guardian Signature

Date

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