• Youth Empowered for Success

    Registration Form
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • School Name*
  • Does your child have any medical concerns*

  • Medical Information

  • Please select or add any medical concerns.*
  • Format: (000) 000-0000.

  • I acknowledge that I have complete understanding of the potential risk associated with this activity, including injury and death, and I voluntarily agree to assume all such risk. I hereby release, discharge, indemnify, and agree to hold all agencies, its officers, agents, and employees, harmless from and against any and all liability, claims, actions, suits, damages, losses, or injuries of any kind, nature or description, including without limitation personal injuries and / or death, medical expenses, and economic damages arising or claimed as a result of any act or omission related to the program(s) offered by any affiliated program.

  • Photographs/Video/Internet I hereby give permission for my child’s photograph to be taken and for him/her to be captured on video in connection with the activities of United Community Corporation and to be used in newspaper and magazine articles, on television and other presentations concerning the program, or on the internet. I understand that my child would only be identified by first name, if at all. I understand that my child, identified only by first name or as a member of a group, may also be included on video streams of events over the Internet that are organized and supervised by United Community Corporations’ staff. I give permission for the following information to be made available publicly, at the discretion of United Community Corporation: ● My child’s first name and/or picture ● Video of students in a group ● My child’s intellectual property (such as artwork, poetry, essays, performances, etc.)

  • Should be Empty: