Youth Brigade

Age

Date of Birth

Grade

Which class would you like to be apart of?

Parent/Guardian email

Phone Number where Parent/Guardian can be reached

Emergency Number

What Interests you most about the program?

Is there is anything else that you are hoping to gain out of the program?

Can Parent/Guardian attend Orientation

Yes

Parent/Guardian Signature

First Name

Last Name

Choose how to sign

Draw Type

I certify that as parent/guardian of the participant on this application, I hereby give my permission for the above named individual to attend and participate in the activities sponsored by the City of Code. I do hereby hold harmless City of Code, its Directors, Officers, Employees, Volunteers, or Agents of said organization, for any bodily injury, illness or disease, or for loss or damage to any property or appliance of said child or ward of the participant. I assume the risk and financial responsibility for any injury or liability resulting from his/her participation. In case of a medical emergency, I understand every reasonable effort will be made to contact me. In the event I cannot be reached, I hereby give permission to secure proper treatment for the participant named above. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to him/her. The undersigned does also hereby give permission for the participant to ride in any vehicle designated by the staff of City of Code while attending or participating in activities sponsored by City of Code. I consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the participant while participating in activities sponsored by City of Code, to be used, distributed, or shown as City of Code sees fit.*