2016 2017 youth application

Zeta Phi Beta Sorority, Inc. Epsilon Rho Zeta Chapter Note: Each girl must be registered on a separate form.

Registration Fee: $50 per year YOUTH INFORMATION (P L EAS E P R I N T) First Name

Last First

M.I.

School Name

Grade

Phone No. Please indicate for which group you are registering: T-Shirt Size (Please circle)

Birth Date

E-mail Address

Pearlettes (ages 4-8) Youth: Small

Medium

Amicettes (ages 9-13) Large X-Large

Adult: Small

Archonettes (ages 14-18) Medium Large

X-Large XX-Large

PARENT/GUARDIAN INFORMATION & EMERGENCY CONTACT PERSON INFORMATION Parent/ Guardian Full Name

Relationship to Youth

Home Phone

Cell Phone

Address E-mail Address Youth lives with: Emergency Contact Person’s Full Name

Phone No.

Please indicate how your youth will be transported to and from meetings/functions:

DISCLAIMER AND SIGNATURE

IMPORTANT: Who is authorized to drop off and pick up your child? (For liability purposes, this person (s) must be over the age of 18) Name of Authorized Person & Relationship to youth:

Please read and sign below.

I agree to have my child participate in the Pearlette, Amicette, and/or Archonette Clubs of Zeta Phi Beta Sorority, Inc., Epsilon Rho Zeta Chapter. I understand that vulgar, lewd, violent, and other inappropriate behavior will not be tolerated. I also understand that my child may be dismissed from the club if the Youth Auxiliary committee feels that her conduct does fit with the ideals of the sorority.

Signature

Date

I.

I/We,

MEDICAL RELEASE

, are the parent(s)/guardian(s) of

After having fully considered the possibilities of harm arising out of or in connection with reasons of illness, injury, accident or death incurred or suffered by our child’s participation at _ (programs/conference), I/we, as the parent(s)/guardian(s) do accept the responsibility for any and all injury to our child which may occur during travel, participation in activities, and any other time during the __(program/conference).

I/We certify that our child is in good health, and free from any disability that would make her participation in the program/conference inadvisable.

As the parent/legal guardian, I request that in my absence the above named child be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic, operative procedures and x-ray treatment of the above minor.

I have read this release and indemnification agreement and understand its meaning. This release is intended to bind my heirs, representatives, successors, assigns and administrations.

Signature of Parent(s)/Guardian(s)

Date:

Address Telephone:

City/State/ZIP Cell#:

Office#:

Insurance Carrier

Policy#

Family Physician

Phone

Please list emergency number(s) at which another relative may be reached during the program/conference.

Name

Relationship:

Telephone:

Name

Relationship:

Telephone:

Name

Relationship:

Telephone:

Name

Relationship:

Telephone:

.

II.

I/We,

HEALTH INFORMATION

, are the parent(s)/guardian(s) of

.

Child’s Birth Date: General health: (check one)

Good

Fair

Poor

1. Known allergies of child, including allergies to medicine:

2. List any medical problems which should be noted:

3. Is your child currently taking any medication?

Medication

Dosage

Ye s

No

Times Per Day

Condition

1.

2.

Signature of Parent(s)/Guardian(s)

Date:

Notice: The information above is required in order for your child to participate all programs/conferences. If your child does not have medical insurance, please indicate under insurance carrier.

Zeta Phi Beta Sorority, Inc. Epsilon Rho Zeta Chapter Youth Auxiliary Photograph, Videotape, and/or Sound Recording Authorization & Release Form

I

(Parent/Guardian Name) of

(Youth’s Name), hereby

voluntarily and without compensation, authorize and consent that Zeta Phi Beta Sorority, Inc., Epsilon Rho Zeta Chapter, its legal representatives, successors, or assigns, shall have the absolute right to copyright, publish, use, sell, or assign any and all photographic portraits or pictures, videotapes, other media material, and/or sound recordings, or any part thereof, they have taken or made of me on this date or in which I may be included in whole or in part, whether apart from or in connection with illustrative or written printed matter, story or news item, motion pictures, or for any other lawful purpose whatsoever, in conjunction with my own or fictitious name, or in a reproduction thereof in color or otherwise.

I hereby waive all claims for any compensation for such use or for damages. I hereby waive any right I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection there with or the use to which it may be applied. I hereby warrant that I am of lawful age and have the legal capacity to contract in my own name in the above regard. I state further that I have read the above authorization and release, prior to its execution, and that I am fully familiar with the contents thereof.

Signature

Date

Name (Please Print)

Signing For

Note: For youth under the age of 18, this form must be signed/co-signed by a parent or legal guardian.