Liability Waiver / Cyss Youth Program Registration & Sponsor Consent Page 3

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SPONSOR CONSENT: I, _________________________, parent/guardian of ______________________, give consent
for an authorized CYSS representative to obtain medical/dental care for my youth in an emergency situation where
his/her condition represents a serious or imminent threat to his/her life, health, or well being. I understand that a
conscientious effort will be made to notify me prior to such action and the expense, if any, will be paid by me.
Treatment at an Army medical facility may be provided without additional consent under the provision of AR 40-3.
Does your Youth have any special needs (asthma, allergies, ADHD, physical disabilities, dietary restrictions, etc.)
Yes ___ No___ (If yes, DA form 7625-1 will be sent to you for completion and must be returned within 5 days.)
Can your Youth be photographed while participating in a CYSS program for release to the media? Yes____ No____
Does your Youth have permission to access social networking sites? Yes ____ No ____
If yes, does your Youth have permission to access the internet?
Yes____ No____
I have reviewed the information on this form and to the best of my knowledge, the information is accurate.
DATE: _______________________
Parent/Guardian SIGNATURE: ______________________________________
Name of verifying parent:___________________________________________________
Staff Name_______________________________________
Verification Date___________ Time_________________________
Special needs? Y or N
If yes, date DA 7625-1 sent to parent:________________ Date returned:_______________________
Date CYSS pass issued:_________________________
Staff Signature___________________________________________
We look forward to seeing you in our programs and encourage parents to drop by anytime to see the great
things happening in our Youth Programs. If you would like more information, please call one of the
numbers listed below:
Youth Program Information:
Parent Central Services Information:
(CYS: Affix bldg. number, location, phone & fax numbers, program e-mail address and days/hours of operation
1. Youth may attend the regular Youth Programs (no field trips or special events until registration is
finalized) as a guest member immediately upon receipt of completed form.
2. CYSS staff will validate form registration. If registration is not validated within 5 working days
from receipt of form, youth’s guest membership will be cancelled.
3. Once registration is validated (and, if required, DA 7625-1 is completed and returned), annual
pass will be issued to youth.
4. Some special events and field trips may cost a nominal fee, but participation in these events is not
mandatory. In the case of field trips, written parental permission must be granted before a youth
is allowed to participate.
5. To enroll in a team sports program, a sports physical is required in addition to this registration.
Sports fees may also apply.
F:\Admin\Teen Center Registration Packets\TEEN CENTER WAIVER & REGISTRATION FORMS


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