GLOBAL YOUTH SUPPORT CENTER

GYSC ONLINE REGISTRATION

Student First Name *

Student Last Name *

Date of Birth *

Gender *

Guardian/Parent First Name *

Guardian/Parent Last name *

Address *

Address 2

City *

State/Province *

Zip/Postal Code *

School *

Grade *

Guardian phone number *

Guardian Email Address *

Ethnicity *

Primary Language *

English Proficiency Level *

Program of Interest *

Preferred way to contact *

Phone

Email

Any

PERMISSION: I hereby grant permission for my child/myself to participate in the above-named Global Youth Support Center (GYSC). In the event of any injury requiring medical attention, I hereby grant permission to the GYSC staff (including volunteers) to attend to my son/daughter or myself including seeking medical attention.

WAIVER: I/we recognize that unanticipated situations and problems can arise during GYSC activities that are not reasonably within the control of the GYSC staff (including volunteers). I/we therefore agree to release and hold harmless the Global Youth Support Center Directors, its agents, officer, employees, and volunteers, from any and all liability, claims, suits, demands, judgments, costs, interest and expense (including attorneys' fees and costs) arising from such activities, including any accident or injury to myself or my child and the costs of medical services.

PHOTO PERMISSION/RELEASE: I understand, as parent/legal guardian of the above-named child, that there are times when the local news media, national news media and/or nonprofit organizations partnering with GYSC request the opportunity to videotape, take photographs and/or interview children within the GYSC. By signing this release, I also give permission to GYSC to make or use pictures, slides, digital images, or other reproductions of me, of my minor child or of materials owned by me or my child, and to put the finished pictures, slides, or images to use without compensation in broadcast productions, publications, on the Web, or other printed or electronic materials related to the role and function of the GYSC. I understand that by signing this, I am, on behalf of myself and my child, releasing GYSC and its directors, officers, employees and agents, from any future claims as well as from any liability arising from the use of any photograph or other images. This form shall be valid for the duration of the current GYSC program. I further give my consent to the GYSC program (in aggregate form) to share the participant's records with each other, for purposes of educational support and assistance. In addition, I understand that the GYSC may use the participant's records to evaluate individual progress and improvement, as well as to evaluate the overall impact of the program to obtain continued funding for the program.

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You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.

Student Signature *

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Parent/Guardian signature (If student is under 18) *

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