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Membership Application

Participant Information (Identifying information for the minor child)

Gender

Maximum file size: 50MB

Race
Resident Status – Check one

List Identifying/Demographic Information for Parent/Legal Guardian

Parent/Guardian Information

Address
Address
City
State/Province
Zip/Postal
Race
Resident Status – Check one
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Benefit Information

(Check the Government Benefits the Family Receives – Check all that apply
(Check the box for the benefits the family has received in the last 30 days; If the family does not receive benefits from the Government, check the first box)

Membership Application

Agreement to Participate and Liability Waiver for Minors Participating in Young People In Action International (YPA) Programs.   I/We, the parent/legal guardian, of said minor child do permit my child to be a member of and participate in all Young People In Action International (YPA) activities/Events. As the parent/legal guardian of the above child. I further give and/or forbid permission for the following:
My above named child to be transported by a YPA staff/volunteer driver.
The adult in charge to arrange for emergency medical attention if I cannot be reached
The above named child to be photographed and/or video taped during activities/events and for the images and/or recordings to be published, reproduced, or distributed by YPA and its affiliates in all outlets, including, but not limited to, television, newspapers, Internet, recruitment materials, and ads without liability or limitation on my or my minor’s part.
The above named child has permission to be a part of our on-line community (www.ypaworld.org, www.youngpeopleinaction.com)

Emergency Contact(s)

Name
Name
First
Last
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Acknowledgement

Whereas, said Parent/Guardian permits said youth to participate in the YPA afterschool program and the YPA Chapter-Venturing Crew weekly meetings. Whereas, said Parent/Guardian permits said youth to participate in the YPA aforementioned activity as described above. Whereas, this document establishes the fact that all parties understand and except the terms of this activity permission form and hereby agrees to hold harmless Young People In Action International and/or any of its partner’s, employees, and/or volunteers, and agrees to never institute any action or suit at law or in equity against, Young People In Action International and/or any of its partner’s, employees, and/or volunteers, or to prosecute or in any way aid in the institution or prosecution of any claim, demand, action, or cause of action for damages, costs, loss of services, expenses, or compensation for or on account of any damage, loss or injury either to person or property, or both, whether developed or undeveloped, resulting or to result, known or unknown, past, present or future, in connection with or arising under or out of any course, class or activity connected with, directed by, related to or conducted by Young People In Action International and/or any of its partner’s, employees, and/or volunteers, and declare under the penalty of perjury that the information which has been provided in this document is true and correct to the best of their knowledge, information and belief and in good faith have placed their official signatures of approval, below, affirming these facts.
Parent Name
Parent Name
First
Last
Guardian’s Name
Guardian's Name
First
Last
YPA Staff Name
YPA Staff Name
First
Last
Witness Name
Witness Name
First
Last