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The Austin17House is a judgment free resource facility that encourages creativity and supportive programming for both middle and high school aged youth and families. To ensure that the youth have a safe environment to enjoy, we ask that you please fill out as much information on this waiver as you can so that we can better serve you and your child. 

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Youth Information

Youth Name (Full Name) *

Date of Birth *

Home Address *

Town, State and Zip Code

Middle/High School Youth Attends: *

Parent/Guardian Name #1 *

Phone Number for Parent/Guardian #1 *

Parent/Guardian's #1 Email (if different from above)

Parent/Guardian's Name #2:

Phone Number for Parent/Guardian #2:

Parent/Guardian's #2 Email (if different from above)

Emergency Contact Name: *

Phone Number for Emergency Contact: *

Physician Name: *

Physician Phone #: *
Medical History
Does your child have any allergies (i.e. pollens, medications, food, insects)?*
No
Yes

If yes, please explain:
Does your child suffer from, or has ever experienced, or is being treated currently for any of the following (please circle all that apply):
Asthma
Epilepsy/Seizure Disorder
Heart Trouble
Diabetes
Frequent upset stomach
Physical Handicap

Should your child's activities be restricted for any reason? Please explain:

Medical History

If necessary, please describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability or condition to which your child is subject and of which the staff should be aware of, and what, if any action of protection is required on account thereof. 


Please fill out here:
Tell Us More!

Austin17House is aware of many of the social determinants that affect our youth and families today, and we work closely with organizations and partners to ensure that all participants and members who join us have options for support where needed. As a non-profit organization we also have opportunities to receive grants and donations for families who are in any public assistance programs. 

Does your family participate in any public assistance programs?
Free and reduced price school (breakfast, lunch, supper)
TANF
Food Pantry/Soup Kitchen
Public Housing/Section 8
Food Stamps/SNAP
WIC/CSFP
Heat/Electric Assistance
SSDI
Head Start
Town Welfare
Medicaid
SSI
Wrap Around Services
IEP
504

If other, please specify
Photo Release and Social Media Permission
I authorize and grant Austin17House the right to use, adapt, make copies, distribute, and publicly display, in any format now known or later developed, all photographs taken of me or my child, by A17H, without present or future compensation. I further agree that any photographs taken of me or my child may be reproduced in any materials, including newsletters, web sites, or social media intended to publicize A17H events or activities.*
Yes
No
Rules of Conduct

For your information, we expect each student to respect these rules of conduct: 

  • No possession or use of alcohol, drugs, and/or tobacco products including e-cigarettes and juul products

  • Students are not allowed to leave and come back to the center without parent permission

  • No fighting, weapons, fireworks, lighters, or explosives

  • No offensive or indecent clothing

  • No offensive language

  • No public displays of affection

  • Participation during group activities is suggested

  • Respect property 

  • Respect others, staff and volunteers

  • Respect and comply with event schedules and rules 

*Students who fail to comply with these expectations will receive an incident report that a volunteer must provide and communicate to the parent.


I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth activities. I agree to respect the expectations laid out above. (Please have student type in name here) *
Consent Form
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Austin 17 house (A17H) and it's volunteers from any liability against personal losses of name child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by A17H. I/We understand that there are inherent risks involved in any community center or athletic event, and I/we hereby release A17H, it's volunteers, staff and board members from any liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. *
I Agree
I Disagree
In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by A17H. I/we acknowledge that we will ultimately be responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above through the date listed on this form. *
I Agree
I Disagree
I/we also, hereby give permission for my child to take over the counter medication (Tylenol, Ibuprofen, Tums, etc.) at the recommended dosage. Please indicate any/all over the counter medication your child is allergic to or you do not give permission to take. Please specify if it is an allergy. *
I Agree
I Disagree

Today's Date

Additional Notes

Sexual Harassment and Austin17House

Please read and confirm below.

Austin17House is committed to providing youth, families and volunteers with an environment that is free from discrimination and unlawful harassment. Actions, Words, Jokes or Comments based on individual's Sex, Race, Ethnicity, Age, Religion will not be tolerated. A17H encourages volunteers to bring any incidents of sexual harassment to the immediate attention of the Executive Director.*
I confirm I have read and agree to reach out to the Executive Director to make any sexual harassment claims.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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