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Youth Services Registration Form
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College Readiness Summit
Date of Birth
*I certify that I am I High School Senior
Confirmed that student is a High School Senior
Emergency Contact Information
Emergency Contact Person #1
Emergency Contact Person #2
Allergies - Health - Special Considerations
Emergency Medical Release
I/We the parents/legal guardian give permission for any treatment necessary during during the transportation and attendance of this event. I/We authorize any hospital and physician to perform emergency treatment for any injuries.
Confirmed Emergency Medical Release
I grant permission for my child, named above, to participate in the City of Surprise College Readiness Summit in Surprise, AZ. I hereby release the City of Surprise from all liability, losses, damages to or destruction of property arising out of or in any way connected with my child's participation in the City of Surprise College Readiness Summit, except when such injury or damages shall have been occasioned by negligent or wrongful acts of omissions the employees or offices of the City of Surprise.
Media & Photography Release
The City of Surprise is permitted (unless indicated otherwise by the participant) to take pictures for use by television, film, radio or print media to further the aims of the City of Surprise programs in related campaigns and magazine articles, booklets, posters and in other ways they may see fit.
Confirmed Media & Photography Release
I understand that checking this box confirms that I acknowledge the electronic signature as a legal signature.
Acknowledgement of legal electronic signature
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