Please Check Your Child’s Age 4 - 8 years - School Location: Clarence Rogers School 9 - 13 years - School Location: Barnard Environmental Magnet School
2012 Application HOW TO APPLY CHECKLIST (1) Fill out the Personal Information below (yellow) (2) Have Parent/Guardian complete the Consent and Liability Form on back (yellow) (3) Have child complete the Youth Questionnaire (green) (4) Have Parent/Guardian complete the Health Questionnaire (blue) (5) Have a Medical Practitioner complete the Health Exam form (pink) (or attach copy of school exam) (6) Send in your payment and/or trip & t-shirt fee (white) (7) Once complete, mail to the Solar Youth office: 53 Wayfarer Street, New Haven, CT 06515 by
JUNE 29, 2012 Return completed applications as soon as possible! They will be accepted for youth registration on a first-come first-served basis.
We hope to see you soon! Child’s Information: Yes No
Has child been in Solar Youth before?
Child’s T-Shirt Size
Child’s First Name
Child’s S M L XL XXL Other: _______________________
Female Black/African American Hispanic/Latino Other Ethnicity White/Caucasian Native American Asian/Pacific Islander Male Child’s Current Yes Housing Authority Child’s Current Grade Resident? School No Gender
Parent/Guardian Information: Parent/Guardian First Name
Relationship to Child
Work Phone Number
Emergency Contact (in case Parent/Guardian can not be contacted) Emergency Contact First Name
Home Phone number
Relationship to Child
Work Phone Number
Mobile Phone Number
Emergency Contacts should be 18 years old or older
Number of people in your household Youth ______ Adults(18+) _______
Household Income: less than $49,830 between $49,831 and $61,555 between $61,556 and $73,280 Over $73,281 over $73,281
By signing below, I give permission for ________________________________________ to (fill in youth’s name)
participate in a Solar Youth program. As a condition of participation in the program, I hereby agree, on behalf of myself and the Participant, as follows: 1. I am the parent and/or legal guardian of the Participant. 2. I understand that participation in Solar Youth involves trips to locations within and outside the City of New Haven, and I give permission for the Participant to attend all such trips during the duration of the program. 3. I forever release, discharge, waive, and covenant not to sue Solar Youth, its officers, directors, employees, agents, volunteers, contractors, predecessors, successors and assigns (collectively “Releasees”) for any liability, claim, damage, action, cause of action, loss, cost, or expense (including attorneys’ fees) of any nature whatsoever arising out of or relating to any loss, damage, personal injury, or death sustained by the Participant while participating in a Solar Youth program, whether on or off Solar Youth’s premises, or travelling to or from Solar Youth’s premises, including but not limited to any loss, damage, personal injury, or death caused or alleged to be caused by the negligence or future negligence of the Participant or the Releasees. 4. I shall indemnify and hold harmless the Releasees from and against any liability, claim, damage, action, cause of action, loss, cost, or expense (including attorneys’ fees) of any nature whatsoever arising out of or related to any loss, damage, personal injury, or death, sustained by the Participant, or alleged to be caused by the Participant, while participating in a Solar Youth program, whether on or off Solar Youth’s premises, or travelling to or from Solar Youth’s premises, including but not limited to any loss, damage, personal injury, or death caused or alleged to be caused by the negligence or future negligence of the Participant or the Releasees. 5. If the Participant requires emergency or urgent medical care while participating in a Solar Youth program or travelling to or from a Solar Youth program I hereby authorize any agent, officer, volunteer or employee of Solar Youth, to act in loco parentis, to transport the Participant to a doctor or hospital, and to consent to emergency or urgent medical treatment, including but not limited to emergence surgery, for the Participant until I or another parent/legal guardian of the Participant can be contacted to give or withhold consent for such medical treatment. I assume the responsibility for all medical bills that may result from such services. 6. I give permission for photos, video or artwork of or by the Participant to be used for promotional material by Solar Youth. 6. This Consent and Liability Form shall be binding upon myself, the Participant, and our heirs, administrators, executors, personal representatives, and assigns. 7. By signing below, I certify that I have read and reviewed this Consent and Liability Form, and understand all of the foregoing provisions.
Printed Name: _____________________________________________________________ Signature: __________________________________________Date:__________________
If you have any questions about this Form, please call Solar Youth at 203.387.4189