Sweet Home Rural Youth Leadership Summit 2019
Registration Form
Please Print:
I ____________________________________ give permission for my child to participate in the
Sweet Home Rural Youth Leadership Summit on Saturday July 27
th
2019. I understand that my
child may not participate in this activity without medical insurance. I also understand that the
City of Sweet Home or any of its branches are not liable for any injury or damage to personal
property that may occur as a result of your child’s participation in this event.
Participants Name _____________________________________________________________
Address ______________________________________________________________________
Parent Name _________________________________________________________________
Primary Phone Contact #1 __________________________ #2__________________________
School Name ______________________________________________ Home School Y / N
Year in School Junior High/High School _________________ 2019 Graduate ______________
Doctors Name _________________________________ Ph # ____________________________
Medical Insurance Co. ___________________________________________________________
Allergies ______________________________________________________________________
Medical Release: I hereby authorize my child’s participation in the Sweet Home Youth
Advisory Council Leadership Summit Event. I know of no mental or physical problems which
may affect my child’s ability to safely participate. The Sweet Home volunteers who are
attending the event are authorized to attend to or seek assistance for any health problem or
injury that may occur at the event. I understand that my child must have current and active
medical insurance before they can participate. Neither my child nor I will hold any of the staff
members, volunteers, sponsors, agents, directors, Linn County, City of Sweet Home or any of
its branches, and representatives liable for injuries or expenses relating to injuries or
damaged property that happen while my child is participating in or attending this event.
Furthermore, I grant permission to all the forgoing to use my child’s name and images in
any photographs, motion pictures, resulting publications, or any other print, video graphic or
electronic record of this event for legitimate purposes.
If under the age of 18 I declare that I have my parent or guardian’s consent to participate in
this event. And that they have read and agree to the above stipulations on my behalf.
Signature of Participant ______________________________________ Date_______________
Signature of Parent/Guardian _________________________________Date_______________
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