GAME ON VIDEO GAME TRUCK

Game On Long Island Video Truck

Youth's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth*
School*
Grade*
Allergies:*
Parent or Guardian Name*
First Last
Parent or Guardian Cell Phone*
Email*
Consent*
I hereby give my permission for my child to attend the REACH CYA Video Game Truck & School Supplies Giveaway
I understand:

 The program will be supervised by REACH CYA staff.
 You release REACH CYA staff,
Board of Directors, volunteer chaperones, and all funding sources from any liability or legal action.