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NAME _____________________________________________ BIRTH DATE_____/_____/_______ AGE____ GENDER____
ADDRESS___________________________________________ PARENT NAME___________________________________
CITY_______________________________ ZIP_____________ BEST#_____-_____-_______ TEXT#_____-_____-_______
PRIMARY EMAIL _____________________________________ ALT. EMAIL______________________________________
SCHOOL____________________________________________ GRADE___ STUDENT ID/LUNCH#___ ___ ___ ___ ___ ___
Asian/Pacific Islander
Black/African American
Caucasian/White
Hispanic
Native American
Other
Parent or Legal Guardian must read and sign below for child to participate in YouthCity
Release & Indemnification: I hereby recognize and acknowledge that my
child’s participation in activities may involve bodily injury and/or emotional injury
to myself and/or child. In consideration of my child being permitted to participate
in such events, I for myself, my child, my heirs, my executors and
administrators, hereby voluntarily and knowingly release negligence based on
any injury except that caused solely by the willful misconduct of YouthCity staff,
that may result from my child’s participation.
Refunds: YouthCity may withhold 25% of the refund (program registration fee)
for administrative costs. All refunds may be requested in person, accompanied
with a written refund request. No refunds shall be given after the first day of the
program.
Collections: I agree to pay Salt Lake City Attorney’s Office for collection. I
understand that any account delinquent 30 days or more will be turned over to
the Salt Lake City Attorney’s Office for collection.
Emergency Treatment: I hereby authorize Salt Lake City program staff to act
on my behalf in accordance with their best judgment in case of an emergency
involving my child, and agree to assume full responsibility for all expenses,
medical or otherwise, that may arise there from. I understand that I or my
insurance company will be billed for such emergency treatment.
Transportation Permission: I hereby give my permission for YouthCity
personnel to transport my child or ward for field trips.
I hereby agree and voluntarily assume all risk, which may be associated with or
result from my child’s or ward’s transportation to the YouthCity Program. I
further agree to release the Salt Lake City School District, YouthCity, Salt Lake
City Corporation and Salt Lake County, its agencies, departments, officers,
employees’ agents and all sponsors and/or officials and staff of any said entity
or person, their representatives, agents’ affiliates, directors, servants, volunteers
and employees from any and all liability, claims, demands, actions and causes
of actions whatsoever for any loss, claim, damage, injury, illness, attorney’s
fees, or harm of any kind or nature to me or my child or ward arising out of any
and all activity associated with the aforementioned activities. I have carefully
read and understand the contents of this form concerning the
transportation of my child or ward.
Photo Permission: I give permission for photographs and videotape recordings
of my son/daughter’s participation in activities with Salt Lake City to be used in
promotional materials for this and other partner programs. I understand that
these photos and/or videos may be used in brochures, edited video programs,
online and other promotional items for informing interested parties about Salt
Lake City activities.
Equal Opportunity: Salt Lake Corporation YouthCity provides equal
opportunity to participants regardless of race, creed, gender or ability to pay,
and will upon request, provide reasonable accommodations to individuals with
disabilities.
Nondiscrimination Statement: In accordance with Federal civil rights law and
U.S. Department of Agriculture (USDA) civil rights regulations and policies, the
USDA, its Agencies, offices, and employees, and institutions participating in or
administering USDA programs are prohibited from discriminating based on race,
color, national origin, sex, religious creed, disability, age, political beliefs, or
reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA. Persons with disabilities who require alternative
means of communication for program information (e.g. Braille, large print,
audiotape, American Sign Language, etc.), should contact the Agency (State or
local) where they applied for benefits. Individuals who are deaf, hard of hearing
or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made
available in languages other than English. To file a program complaint of
discrimination, complete the USDA Program Discrimination Complaint Form,
(AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html,
and at any USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your completed form or letter to
USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant
Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C.
20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
By signing this document, I acknowledge that I have read its contents and disclosure, and that I agree to its terms.
PARENT SIGNATURE______________________________________________
DATE______/________/____________
R E G I S T R A T I O N F O R M
