Application and Permission Form

Name of Participant*

Age*

Name of Parent/Guardian*

Address*

Street Address City State ZIP Code

Email*

Phone*

Name of Program*

Location*

Date(s) of Program*

Time*

Please Confirm*

I confirm that I am the parent or guardian for the child or teen listed above. I give my permission for them to participate in this program. I understand that participation is at their own risk, that Amorak, its directors or members, any collaborating organization and the facilitator are not responsible for any injury or illness associated with the activity. The facilitator may arrange transportation during the program. If so, I give permission for my child to be transported to the program. Otherwise, the parent/guardian is responsible for transportation

Photograph Permission*

I do /do NOT give permission for photographs of my child to be used in promoting Amorak programs on its website, social media, in the newspaper or in any other media form.

I Do
I Do NOT

Please list any severe allergies, physical limitations or medical conditions you feel we should know about:

Emergency Contact*

Must be different from parent listed above

Emergency Contact Phone*

Promoting Strength, Pride, Loyalty and Hope