West Hollow MS Babysitting / Home Alone Workshop

West Hollow MS Babysitting (1)

Youth's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth*
MM slash DD slash YYYY
Gender
- Female
- Male
Ethnicity
- American Indian or Alaska Native
- Asian
- Black / African American
- Hispanic or Latino
- Native Hawaiian or Other Pacific Islander
- White
Grade*
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 Babysitting/Home Alone Workshop
I understand:

 The program will be supervised by REACH CYA staff.
 REACH is not responsible for any personal items left behind.
 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.