Issuu on Google+

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

Last Name

Address

Apt. #

City

Zip Code

Child’s  S  M  L  XL XXL Other: _______________________

Birth Date

Home phone

Month

/

Day

/

Year

Cell phone

 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

Last Name

Relationship to Child

Mobile Phone#

Work Phone Number

Work Hours

Parent/Guardian Email

Emergency Contact (in case Parent/Guardian can not be contacted) Emergency Contact First Name

Last Name

Home Phone number

Relationship to Child

Work Phone Number

Work Hours

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


Solar Youth Summer Camp 2012 Application