Youth Registration Form (NEO)

Please answer the questions as accurately as you can. The information you provide helps Bright Futures for Youth secure funding to keep our programs free. All information is kept confidential and anonymous. This form must be completed in order for your child to participate in our programs.
Caregiver & Emergency Contact Information
Parent/Guardian 1 (LG1)






(landline only; in case of emergency)








(uncheck above if you do not wish to receive SMS (text) notifications, events, and other communications from program staff.)
Parent/Guardian 2 (LG2)








(landline only; in case of emergency)




Address





(uncheck above if you do not wish to receive SMS (text) notifications, events, and other communications from program staff.)
Other Emergency Contacts (EC1 | EC2)








(landline only; in case of emergency)















(landline only; in case of emergency)








Other Authorized Pick-up Contacts (AP1 | AP2)







(landline only; in case of emergency)
















(landline only; in case of emergency)








Youth General Information
Youth Information











(Select grade; entering in fall semester)
Youth & Household Demographics
The following section requests necessary demographic information to fund our programs so that we may keep them free for participating youth. We want to ensure you that Bright Futures for Youth keeps the information you provide confidential and anonymous, and never shares it with personal identifiers attached.






(if other, provide details of youth's ethnicity)

(input numerical number; 0-9)

Youth Health Information
Part I: Medical Insurance


(if no insurance, type NONE)

(provide details of other insurance)
Part II: Medical Conditions & Treatment

(check all that apply)

(provide brief description of the illness and/or injuries checked above)

(check all that apply;)

(provide brief description of the health condition checked above)

(Bright Futures for Youth staff may have permission to administer the following as necessary; check all that apply)
  • Acetaminophen: reduce pain or fever (i.e., Tylenol, Anacin II)
  • Ibuprofen: anti-inflammatory for swelling or fever (i.e., Advil, Nuprin)
  • Naproxin: anti-inflammatory for swelling or fever( i.e. Aleve)
  • Calcium carbonate: slight upset stomachs (i.e., Tums, Maalox, Mylanta)
  • Digestive enzymes: reduce bloating and digestive pain related to certain foods (i.e., Bean-O, Lactaid, etc.)
  • Antibiotic ointment: cuts or scratches
  • Eye lubricant: eye drops
  • Eye rinse: eye irritation
  • Meclizine: antihistamine (i.e., Dramamine)
  • Hydrocortisone: anti-itch cream
  • Benzocaine: oral pain gel
  • Lidocaine: burn gel
  • Diphenhydramine: soothes insect bites (i.e., Caladryl, Benadryl, Cortizone) or wounds and aching muscles (i.e., Neosporin, Bengay)
  • Aloe Vera: after sun care
  • Zinc oxide: sunburn prevention
  • Sunscreen containing PABA: sunburn prevention
  • Insect repellent containing DEET: prevents insect bites, including mosquitoes and ticks
NO MEDICATION WILL BE DISPENSED TO A MINOR WITHOUT PARENT/GUARDIAN CONSENT

Part III: Allergies

Allergy Information
To add more allergies, click on "Add another allergy" below in this section.



Describe the severity of the allergic reaction.

Part IV: Immunization & Vaccination

(check all that apply)
Part V: Mental & Behavioral Conditions

(if no conditions or no special care requirements, type NONE)


(provide additional information on the assessment/plan if needed)

To the best of my knowledge this health history is complete and accurate. I know of no reason(s), except as I have indicated on this form, why member cannot participate in all activities. If there is any change in member’s health condition that would affect participation in activities, I agree to advise Bright Futures For Youth and update this history in writing immediately.

Authorizations and Agreements
YOUTH CONSENT


(for field trips involving water, please rate your child's swim ability)

(movie rating your child is permitted to watch; check all that apply)
FIELD TRIP PERMISSION

Field trips will be a part of all Bright Futures for Youth (BFFY) programs. Depending on where the field trip is located, we will get to the location by either walking, riding in a school bus, or being driven in BFFY vehicles or private cars by staff and/or volunteers. This form will cover all field trips that your child will participate in.


I authorize Bright Futures for Youth to take my child on all field trips taken as part of their participation in BFFY programs and activities. I certify that I am aware of the inherent risks associated with field trips. In consideration of my child's participation in these trips, I agree that Bright Futures for Youth, and/or its employees, will not be responsible for any accident however caused. I hereby release the above parties from all claims, liabilities, and/or damage that may arise as a result of such accident or loss.


MEDIA RELEASE FORM
I _________________________, do hereby give Bright Futures for Youth (BFFY) and parties designated by Bright Futures for Youth permission and the right to use my child’s name, testimonials, photographs and video recordings for reproduction in any medium for purposes of editorial, trade, advertising, display or exhibition use. The medium may also include social media. Bright Futures for Youth and its affiliated programs, including The Friendship Club, NEO and SAFE, have multiple social media accounts, including on Facebook and Instagram.

I hereby waive any right that I may have to inspect and approve the finished product or copy that may be used in connection with an image or video that was taken of my child or the use to which it might be applied. I further release Bright Futures for Youth and their representatives from any claim associated with any form or damage, foreseen or unforeseen, associated with the commercial or artistic use of these images unless it can be proven that said reproduction was maliciously caused, produced and published for the sole purpose of subjecting my child to conspicuous ridicule, scandal, reproach, scorn and/or indignity.

I have read this release and fully understand its contents.

RELEASE OF LIABILITY

I understand that the opportunity to participate in Bright Futures For Youth (BFFY) activities is a privilege. In consideration for that privilege, I am signing this Release of Liability form on behalf of my minor child. I understand that my child may participate in any number of physical activities some of which include, but are not limited to: recreational activities and games and events. I understand that there are certain risks of physical injury or illness associated with these activities. In addition, I understand that there may be other risks associated with these activities of which I may not be presently aware.

By signing this Release, I expressly assume these risks for my child, whether such risks are known or unknown to me at this time. I release BFFY, and their officers, directors, volunteers, employees, contractors and agents, from any claim that my child may have now or in the future against them for any accidental physical or other personal injury, loss of personal property, illness or death caused by infectious and/or contagious diseases or sickness while at BFFY activities, or during travel to and from BFFY activities, and any medical responses to the same, as well as any other claims arising from participation in BFFY activities. This Release of Liability shall cover (without limitation) all claims for negligence and breach of fiduciary duty asserted by my child or any person made on their behalf. This Release specifically covers claims caused in whole or in part by any U.S. national health crisis, epidemic, pandemic, or similar widespread outbreak of disease whether or not such is formally declared by the U.S. government, the Center for Disease Control or the World Health Organization.


AUTHORIZATION FOR MEDICAL TREATMENT

With the increasing sophistication of the medical system, I understand it may be necessary to have a medical consent form present in the unlikely event of an injury or condition requiring medical treatment of my child. This consent and release gives Bright Futures For Youth (BFFY) and its personnel the permission to take my child to the nearest, available medical facility and have any necessary emergency treatment administered.


In case of emergency, I understand that efforts will be made to contact me; however, if I cannot be reached, I hereby give BFFY the permission to act on my behalf in seeking emergency medical treatment for my child in the event that such treatment is deemed necessary or advisable for my child's health, safety and welfare. I give permission to those administering medical treatment to do so, using the measures deemed necessary. I release BFFY and all medical providers from liability in acting in this regard and rendering such medical treatment. I will be fully responsible for all such medical expenses.


I represent that I am the parent/guardian of the child named below, who is under 18 years of age. In consideration for allowing my child/ward to participate in BFFY activities, I hereby consent to the foregoing on behalf of my child/ward and agree that this release shall be binding upon me, my child/ward, and our heirs, legal representatives, and assigns.


INDEMNIFICATION
I hereby agree to defend, indemnify and hold Bright Futures For Youth (BFFY) harmless from any liability asserted by my child/ward subsequent to his or her reaching majority, including reasonable attorney's fees and costs. I also warrant that my child/ward is physically fit and able to participate in all BFFY activities.

BFFY Communication

Contact Information