Safe Dates Step 1 of 2 50% Parent InformationName(Required) First Last Email(Required) Enter Email Confirm Email Phone(Required)Address(Required) City State / Province / Region ZIP / Postal Code Who can pick the child up?(Required) Add RemovePlease list the names of these individuals.Additional Information Child InformationName(Required) First Last PhoneGender(Required)MaleFemaleMy gender is not listedPrefer not to answerDate of Birth(Required) MM slash DD slash YYYY Ethnicity(Required) Asian Black/African American Caucasian Hispanic/Latinx Native American Emergency Contact InformationName(Required) First Last Phone(Required)Name First Last PhoneHow did you hear about this event?(Required)Social MediaWord of MouthRefer a FriendPast ParticipantOtherConsent(Required) I agree to the privacy policy.PARENT OR LEGAL GUARDIANSHIP CONSENT, WAIVER, AND AGREEMENT I, the parent or legal guardian, in consideration of allowing my child to participate in all activities, including but not limited to: workshops, mentoring sessions, sports activities, educational programs, and other enrichment activities, all organized by Wilkes Youth Life Development (WYLD) hereby give my consent for my child to participate in such activities during and in preparation for the Unique You Training Program. Consent to Participate My child's participation in these activities is voluntary and I have the right to withdraw my consent at any time. Withdraw of consent shall be made in writing to a WYLD Staff Member. WYLD reserves the discretion to send any child home or discontinue their participation in the program/event. WYLD will take all reasonable precautions to ensure the safety of my child, but there may be inherent risks associated with the activities. Acknowledgement of Risk of Injury/Release and Waiver I will be responsible and assume, on behalf of my child, any medical expenses, any risk, or claims arising from my child's participation in these activities. I take full responsibility, waive, and relinquish any and all claims of any sort whether in tort, contract, equity or otherwise including any claims of personal injury, death or damage to personal property associated with WYLD, including, but not limited to the participation in any volunteer activities, consuming food, recreational activities or otherwise. I indemnify and hold harmless WYLD, and its officers, directors, members, volunteers, agents, and employees from losses, damages, and judgments (including reasonable attorneys’ fees and expenses) arising from arising from my child's participation in these activities. I release and hold harmless WYLD, its employees, volunteers, agents and assigns, from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I or my child ever had or may have, arising from or in any way related to child’s participation in any of the events or activities sponsored by, conducted by, on the premises of, or for the benefit of WYLD. Certification of Ability to Participate and Medical Authorization: I, parent or legal guardian, understand that the activities that my child may participate in could involve physical exertion which may cause serious or grievous injuries, including bodily injury, damage to personal property and/or death. I confirm that my child is in good health and has the necessary and requisite skills to participate in the requested activities and my child’s only limitations or activities from which said child is prohibited are noted above. On behalf of myself, child, my heirs, and assigns, I and my child waive all claims for damages, injuries and death sustained to me or my property, that I or said child may have against WYLD, and it’s officers, directors, members, volunteers, agents, and employees party to such activity. In the case of the illness or injury of my child the staff will try to notify me or the emergency contact listed on the Registration form. In the event of a medical emergency concerning my child at a time when either I or the emergency contact person cannot be notified, I hereby authorize Wilkes Youth Life Development staff or my child’s caregiver, as applicable, to obtain the necessary medical care and/or treatment, including but not limited to first aid, X-ray examinations, and aesthetic, medical or surgical diagnosis or treatment or hospital care and I hereby accept the sole financial responsibility for such medical care, first aid or treatment. I also authorize the facility to disclose these conditions to a physician or other medical professional in the event my child should require emergency medical care. Wilkes Youth Life Development will not administer medications. Early Return Home Policy: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the parent or legal guardian shall assume all transportation costs, responsibility, and liability. Parent or Legal Guardian Consent I have read, understand and fully agree to the terms of this waiver and release. I understand and confirm that by signing this waiver and release my child and I have given up considerable future legal rights. I have signed this waiver and release freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional waiver and release of all liability to the full extent of the law. Media Release Form I, parent or legal guardian, hereby grant permission to Wilkes Youth Life Development ("WYLD"), its employees or representatives to take and use photographs, digital images, video, or other like materials of my child, hereinafter mentioned, for education, promotional, social media, and any other purpose WYLD maintains. These materials might include printed or electronic publications, websites, social media posts, electronic communications, and any other formats. I further agree that my child’s name and identity may be revealed in descriptive text or commentary in connection with the image(s). I understand that WYLD has the right to edit, incorporate, and use this material at its discretion, including the right to include it with sound effects, special effects, and music, and to use it for publicity, advertising, sales promotion, and any other purpose WYLD maintains. I authorize the use of these images indefinitely without compensation to me. All digital copies, prints, and video shall be the property of WYLD. I release and hold harmless WYLD, its employees, volunteers, agents, and assigns, from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, known or unknown, in law or equity, that I or my child ever had or may have, arising from or in any way related to the production, distribution, broadcast, or exhibition of photographs, digital images, video, or other like materials of my child, including but not limited to claims for invasion of privacy or defamation.