Urban Air Trip

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 Urban Air Trip.

I understand:

 The program will be supervised by REACH CYA staff.
 Youth will be transported to event by REACH CYA van.
 REACH CYA does not provide any health/hospitalization insurance for my child.
In 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.