Name of Junior Youth *

First Name

Last Name

Birthday *

MM

DD

YYYY

Name of Parent/Guardian *

First Name

Last Name

Phone *

(###)

###

####

Name of Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Image Release *

Do you permit the use of photos and videos taken of the group’s activities that include your son/daughter to be used in the program’s promotional materials?

Yes

No

Permission to Participate *

I hereby give permission for my son/daughter to attend the activities organized by the Richmond Youth Education Center (RYEC). I understand that RYEC will endeavour to provide my son/daughter with a safe environment. In the case of personal injury, loss or damage I or a third party will not hold RYEC, its agents or volunteers responsible.

Yes, I give permission

No

How did you hear about us? *

Online

Library Booth

Word of Mouth

Other