LSJS Enrollment- ENG | Hyde Square Task Force

LSJS Youth Organizing Enrollment Form:

We are so happy you are going to be a part of Living Safely in Jackson Square (LSJS) Youth Organizing program! Please complete the following forms to finish your enrollment process.

If you have any other questions about enrolling, please reach out to our Recruitment and Enrollment Team at recruitment@hydesquare.org.

Emergency Contact Information: (Parent/Guardian)

We will use this contact information in case we cannot get a hold of you or for any unforeseen emergencies. If you are under the age of 18 one of these contacts need to be a parent/guardian.

Contact 1 Name:*

First Last

Contact 1 Relationship to Participant:*

Contact 1 Primary Phone Number:*

Contact 2 Name:

First Last

Contact 2 Relationship to Participant:

Contact 2 Primary Phone Number:

What is the highest level of education earned by either one of your parent(s) or guardian(s)? (Answer this question for the person who has the highest level of education only).*

Medical Information:

This section of the enrollment form will ask you to fill out information regarding medical conditions or other important medical information for yourself. This information can be used to provide you with resources or to support you in the case of an emergency.

Are there any medical conditions you want us to be aware of:

Do you have any allergies you would like to make us aware of?

Please use this space to inform us of any learning, emotional, and/or behavioral support needs that our staff should be aware of.

Are there any accommodations you will need to participate fully in the LSJS Youth Organizing program?*

If you selected "yes," please explain below:

Are there any self-administered medications you want to make us aware of in case of any emergency?

For example: EpiPen, Inhaler, Insulin, etc.

Do you have health insurance?*

Provide your health insurance provider:*

Provide the name of the policyholder:*

Provide the policy number:*

Consents

Here are HSTF's Medical, Photo/ Video, and Liability forms. Select an option below for each. The signature and date at the end will sign all three forms.

Medical Consent:*

I hereby give Hyde Square Task Force permission to administer basic First/Aid and/or CPR and/or take myself, or my child, to a hospital and secure medical treatment when I cannot be reached or when delay would be dangerous to my, or my child's health.

You have my consent
You DO NOT have my consent

Photo/Video Consent and Release Form:*

I hereby give permission for Hyde Square Task Force (herein referred to as HSTF) to use for educational and/or publicity purposes only any photographs, film, or video taken of me or my child during the course of their participation in HSTF programming. I understand that me or my child and/or any other identifying information may be used in accounts of the HSTF programs, including newspaper and magazine articles, social media, website and other internet materials, television, and other presentations or publications concerning the programs. I understand and acknowledge that my consent to the use of the above information is purely voluntary and is not required by HSTF as a condition of me or my child’s participation in HSTF programming. I knowingly and voluntarily release and hold harmless HSTF, its agents and employees from any liability of any kind resulting from use of the information as set forth above. This release and waiver of liability is binding upon my successors, heirs, and assigns.

You have my consent
You DO NOT have my consent

Release and Waiver of Liability Agreement for Participation:*

You have my consent

This agreement is by and between Hyde Square Task Force (herein referred to as HSTF) and the individual whose name is signed and printed below (herein referred to as participant).

1. I am participating in a program at HSTF, during which I may participate in physical activity workshops. I recognize that participation in such activities requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in a HSTF program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the HSTF program.

3. In consideration of being permitted to participate in the HSTF Program, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program.

4. In further consideration of being permitted to participate in the HSTF Program, I knowingly, voluntarily and expressly waive any claim I may have against HSTF and its employees, board members, officers, volunteers, and staff for damages, and injury, including death, that I may sustain as a result of participating in the HSTF Program.

5. I and my heirs or legal representatives forever release, waive, discharge and covenant not to sue HSTF and its employees, board members, officers, volunteers, and staff for any injury or death caused by my voluntary participation in the HSTF Program.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. This agreement remains in effect for as long as I participate in the HSTF Program.

Participant Signature:*

Parent/ Guardian Signature: (only if participant is under the age of 18)

Date:*