Youth Travel Permission Form


I, [esigninja formid="33" field_id="863" display="value" ] [esigninja formid="33" field_id="864" display="value" ] hereby give permission for my child [esigninja formid="33" field_id="838" display="value" ] [esigninja formid="33" field_id="839" display="value" ] (PARTICIPANT), to attend and participate in the following children/youth activities/trip: [esigninja formid="33" field_id="977" display="value" ].

The following rules and guidelines are equally binding on adult leaders/chaperones and youth participants. Any participant failing to abide by these rules will be sent home immediately at personal/family expense. 

PARTICIPANT INFORMATION

[esigninja formid="33" field_id="838" display="label_value" ] [esigninja formid="33" field_id="842" display="value" ] [esigninja formid="33" field_id="839" display="value" ] 

[esigninja formid="33" field_id="876" display="label_value" ]   [esigninja formid="33" field_id="927" display="label_value" ]

[esigninja formid="33" field_id="960" display="label_value" ]   [esigninja formid="33" field_id="957" display="label_value" ] 

[esigninja formid="33" field_id="860" display="label_value" ]  [esigninja formid="33" field_id="892" display="label_value" ] 

PARENT/GUARDIAN INFORMATION

[esigninja formid="33" field_id="863" display="label_value" ] [esigninja formid="33" field_id="864" display="value" ] 

[esigninja formid="33" field_id="967" display="label_value" ]

[esigninja formid="33" field_id="875" display="label_value" ]  [esigninja formid="33" field_id="874" display="label_value" ] 

[esigninja formid="33" field_id="878" display="label_value" ] [esigninja formid="33" field_id="879" display="value" ] 

[esigninja formid="33" field_id="968" display="label_value" ]

[esigninja formid="33" field_id="884" display="label_value" ]  [esigninja formid="33" field_id="885" display="label_value" ] 

EMERGENCY CONTACT(S) INFORMATION

[esigninja formid="33" field_id="906" display="label_value" ] [esigninja formid="33" field_id="907" display="value" ] 

[esigninja formid="33" field_id="969" display="label_value" ]

[esigninja formid="33" field_id="908" display="label_value" ]

[esigninja formid="33" field_id="913" display="label_value" ] [esigninja formid="33" field_id="914" display="value" ] 

[esigninja formid="33" field_id="970" display="label_value" ]

[esigninja formid="33" field_id="915" display="label_value" ]

NON-NEGOTIABLE RULES

  • Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times
  • Participants will be respectful of both common living spaces and the property of others
  • Participants will avoid the use of foul language, cursing, or any speech (including "humor") which puts down, makes fun of, or stereotypes other persons or groups
  • No use of illicit drugs or alcohol
  • Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions 
  • No sexual activity or sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments) 
  • If the trip/activity is overnight, participants must be in assigned rooms by the designated time
  • Coed visitation only in assigned community room
  • Smoking, vaping, and the use of tobacco products are not allowed to, from, or during any activity/trip
  • Strict adherence to all local, state ad/or national laws
  • Adults and participants will be equally responsible for performing assigned tasks in a timely and cooperative manner
  • Sleeping areas for males and females will be separate

Youth Participant (or Adult Leader) Statement: By completing this form, I agree to respect others during this activity by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file. 

Parent/Guardian Statement: By completing this form, I agree to support the Covenant of Community Expectations printed above, and will accept responsibility for the payment of my child's return transportation should s/he break one of the non­negotiable rules

MEDICAL INFORMATION:

[esigninja formid="33" field_id="930" display="label_value" ]

[esigninja formid="33" field_id="976" display="label_value" ]

[esigninja formid="33" field_id="929" display="label_value" ]  [esigninja formid="33" field_id="897" display="label_value" ] 

[esigninja formid="33" field_id="928" display="label_value" ]  [esigninja formid="33" field_id="896" display="label_value" ] 

[esigninja formid="33" field_id="899" display="label_value" ]

[esigninja formid="33" field_id="980" display="label_value" ]

MEDIA 

I consent for the Louisville Urban League and any of its affiliated organizations and programs, permission to use the likeness of everyone listed in this form in any and all of its publications or advertisements in print, television, online and any other media, without compensation to me. This consent is irrevocable and is without payment.

I understand and agree that the materials may be shared with other organizations and media outlets by the Louisville Urban League. I waive the right to inspect or approve anything in which my name, statement(s) or likeness appears, and I waive any right to royalties or other compensation arising or related to their use.

I hereby hold harmless and release and forever discharge the Louisville Urban League from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

[esigninja formid="33" field_id="925" display="label_value" ]

LIABILITY RELEASE: In consideration PARTICIPANT's involvement in the aforementioned activities/trip,  I hereby release and agree to hold harmless the Louisville Urban League and its partner organizations, directors, employees, and volunteers (collectively) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in activities, including trips away from the premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said organization(s) for any liability sustained as the result of the negligent, willful or intentional acts of PARTICIPANT, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the PARTICIPANT has been entrusted, to seek medical, dental, or hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Louisville Urban League/St. George's. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

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Signature Certificate
Document name: Youth Travel Permission Form
lock iconUnique Document ID: f6e18a5262f3a483c355004e92712689218975d1
Timestamp Audit
October 8, 2019 5:45 pm ESTYouth Travel Permission Form Uploaded by Carla Robinson - [email protected] IP 69.135.110.187
October 9, 2019 12:25 pm EST Document owner [email protected] has handed over this document to [email protected] 2019-10-09 12:25:36 - 98.100.255.218
October 9, 2019 4:06 pm ESTDr. Kish Cumi Price - [email protected] added by Carla Robinson - [email protected] as a CC'd Recipient Ip: 98.100.255.218
October 10, 2019 11:12 am ESTDr. Kish Cumi Price - [email protected] added by Carla Robinson - [email protected] as a CC'd Recipient Ip: 98.100.255.218
October 10, 2019 4:47 pm ESTDr. Kish Cumi Price - [email protected] added by Carla Robinson - [email protected] as a CC'd Recipient Ip: 69.135.110.187
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