1.Your Name:

2.Your Child's Name:

3.Do you, the parent or legal guardian of the above child's name, grant ACTION Coalition permission to use photographs for any legal use, including but not limited to publicity, copyright purposes, illustration, advertising, and web/social media content?

Yes

No

4.Do you, the parent or legal guardian of the above child's name, grant ACTION Coalition permission for the ACTION Staff to obtain our child's cell phone number and/or email address for communication purposes pertaining to the Youth Leadership Group?

Yes

No

5.Please type your full name, which will be recognized as your digital signature

6.Please add anything we may need to know about your child (food allergies, special accommodations, etc.)

7.Please provide your phone number for in the event of an emergency