YTC Registration Form

Participant Information

Name
Name
First Name
Last Name

Parent / Guardian Information

Name
Name
First Name
Last Name
Home Address
Home Address
City
State/Province
Zip/Postal

Second Parent / Guardian Information (Optional)

Name
Name
First Name
Last Name
Home Address
Home Address
City
State/Province
Zip/Postal

Non-Custodial Parent Information (If applicable)

Name
Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal

Emergency Contacts

Emergency Contact 1
Emergency Contact 1
First Name
Last Name
Emergency Contact 2
Emergency Contact 2
First Name
Last Name
In emergencies requiring immediate medical attention, your child(ren) will be taken to the nearest hospital emergency room.
Your signature authorizes the responsible person at Columbia Association to have your child(ren) transported the above listed hospital in case of an emergency.

Child Permissions

Important Permissions (check all that apply)

Supplemental Information

Type N/A if any of the following fields do not apply

YTC staff does not administer medication. Only medication listed on this form — or, in the case of an illness, on the medication order form — will be permitted in the facility.

Terms & Conditions

I give permission to my child to participate in the program(s) offered by Columbia Association’s Youth and Teen Center at The Barn, including off-site and overnight trips or activities.

I understand that my child(ren) shall abide by all the rules, regulations, agreements, criteria and guidelines of Columbia Association’s Youth and Teen Center
at The Barn and that his/her failure to do so will give Columbia Association’s Youth and Teen Center the right to immediately terminate his/her participation. I
understand that I may have to pick my child(ren) up if he/she does not abide by these rules.

I also give permission for my child(ren) to be photographed and videotaped by Columbia Association and authorized members of the media for promotional
material or for any other Columbia Association purposes, including publicity. I release Columbia Association from any and all claims and liability in regard to said photographs and footage.

I understand and voluntarily assume on my own behalf and on behalf of my child(ren) all risks inherent in participation in the programs; and I waive all claims,
actions, costs, liabilities, expenses and judgments against Columbia Association, Inc. and Columbia Association’s Youth and Teen Center at The Barn and
release CA and its directors, officers, agents, representatives, and employees from claims, action, costs, liabilities, expenses and judgments arising out of my child’s participation in the programs. I further agree to indemnify CA and it’s directors, officers, agents, representatives, and employees and hold them harmless for any and all claims, damages, actions, liabilities, and expenses, including attorney’s fees, arising out of my child’s participation in the programs.
Columbia Association has my permission to take whatever steps it deems necessary to properly care for and supervise my son/daughter, including the rendering
of emergency medical care in the event that any situation occurs whereby an agent or employee of Columbia Association’s Youth and Teen Center at The Barn, in the exercise of his/her discretion, assesses that immediate action is necessary and/or in the event my child is injured and I cannot be reached within a
reasonable time under the circumstances.

My signature below indicates my understanding and agreement with all terms set forth in this registration. I agree that I will cooperate fully with all Columbia
Association personnel and will notify Columbia Association’s Youth and Teen Center at The Barn in writing if any information set forth on this registration form changes in any way.