Fillable Liability Waiver / Cyss Youth Program Registration & Sponsor Consent (Page 3 of 3) in pdf

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: ______________________________________

STAFF TELEPHONIC VERIFICATION:

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

Notes:

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.

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