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* 1. Parent/Legal Guardian First Name, Last Name, Phone Number, Address

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* 2. Participant's Name

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* 3. Participant's Birth Date

Date

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* 4. Participant's Gender

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* 5. Participant's School and Grade:

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* 6. Participant's Phone Number

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* 7. Participant's Email

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* 8. Medical Matters:
I hereby warrant that to the best of my knowledge, my child/youth is in good health, and assume all responsibility for the health of my child.

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* 9. Emergency Medical Treatment:
In the event of an emergency, I hereby give permission to call 911 and or  transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency and you are unable to reach me at the above numbers, contact:

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* 10. Allergic reactions (medications, foods, plants, insects, etc.) Please list allergies (food and or other)

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* 11. You should be aware of these special conditions of my youth:

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* 12. Rules, Commitment, Photo Release and Waiver & Release of Liability

LATI has completed a Social Distancing Protocol to prevent the spread of COVID-19.



Registration Approval: Upon registration, you will receive a service call  to confirm.

If your youth has been approved to participate, you will receive an email and or phone call.

Drop off 5:30 am  - Pick Up no later than 7:30 pm: It is the responsibility of the parent / legal guardian to drop off and pick up youth/ participant. Chill Out is a drop in program and is not responsible for students leaving.

COVID Safety Compliant: The state of California and Santa Clara County requirements, social distancing, and mask-wearing will be enforced. Parent must wait until COVID safety check in is complete.

Inappropriate Behavior/Parent agreement: I understand that LATI/Chill Out staff and or volunteers will not allow any form of inappropriate behavior. If my child’s behavior is deemed inappropriate while participating or he/she is under the influence or in possession of drugs and/or alcohol my child will be separated from the other participants and I may be contacted to pick up my child.

Snacks will be provided. youth can also bring own snacks. (LATI/Chill Out does not have allergy food options)


PHOTO RELEASE: I agree, as a participant, parent or guardian of any paid or free event, class, activity, or program to grant full permission to LATI, MHUSD, City of MH, HUB CBOs to use our name(s) and any photographs, videographs, motion pictures, or recordings for any publicity and promotion purposes without obligation or liability to me.

LATI/Chill Out is not responsible for youth leaving early.

Emergency Medical Information: Parent/Guardian is responsible for providing emergency information.


WAIVER & RELEASE OF LIABILITY: The undersigned, in consideration of participation in this program, agrees to indemnify and hold LATI/ SCYTF/ City of Morgan Hill, MHUSD, representatives, volunteers and employees harmless and release LATI, its volunteers, representatives and employees from any and all liability for any injury or loss which may be suffered by the above named individual in this program. I have read the above application and am in agreement and fully understand that I assume all risks for any injuries received. I have followed all procedures for stated under Registration Procedures. I certify that all the above information is true and accurate.

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* 13. Date of Signature

Date

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* 14. My relationship to participant(s)

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