Child Care Permanent Schedule Change Form

High School Action & Advisory Committee

Youth's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Student Cell Phone #:
Student Email*
Date of Birth*
MM slash DD slash YYYY
School*
Grade*
Allergies:*
Parent or Guardian Name*
First Last
Parent or Guardian Cell Phone*
Parent or Guardian Email*
Consent*
I hereby give my permission for my child to volunteer on the REACH CYA Advisory & Action Committee.
I understand:

 The program will be supervised by REACH CYA staff.
 REACH CYA does not provide any health/hospitalization insurance for my child. n the event you cannot be reached in a medical emergency, you give REACH CYA staff authorization to secure proper medical treatment, including taking your above named child to the nearest hospital. You release REACH CYA staff, Board of Directors, volunteer chaperones, designated drivers and all funding sources from any liability or legal action.