Participant Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant Date of Birth *

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Participant Phone Number

(###)

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Name of Parent or Guardian *

First Name

Last Name

Guardian Phone Number *

(###)

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Enlist in our emailing list for upcoming activities we offer through our Youth Programming

Yes, I would like update on future activities through Warp

In Case of an Emergency *

In case of an emergence involving the named minor above, I understand that every effort will be made to contact me immediately and that I (parent/guardian) am financially responsible for medical treatments or procedures necessary as a result of any injury sustained as a result of participation in Warp Corps programs. The adult in charge of the Warp Corps activity or fill out the alternative guardian information below.

I agree

Name of Alternative Guardian

First Name

Last Name

Phone of Alternative Guardian

(###)

###

####

*

I agree, by signing below, that participation in Warp Corps Prevention Program Activities / Adventures is voluntary which means I am not required to sign up; I am expected to be kind to and inclusive of others, regardless of any differences between us; That I agree to abide by governing laws and rules of conduct at any location we visit; I agree to abide by the set transportation plan, especially departure times; I understand the risk involved with physical activities such as weight lifting, action sports, and adventure trips; That I agree to release and Hold Harmless Warp Corps and its employees, volunteers, agents, officers, affiliates, and related parties from any and all claims arising from participation in Warp Corps Adventures. Your participation in Warp Corps Adventures constitutes your consent to be photographed, filmed, or otherwise recorded and to the release, publication, exhibition, or reproduction of any and all recorded media of your appearance or voice for any purpose whatsoever in perpetuity in connection with Warp Corps. You understand that photography, filming and/or recording will be done in reliance on this consent. If you do not agree to the foregoing, I will not participate in Warp Corps Adventures.

I agree

ROI Consent *

By checking the box below and signing the Activity and Transportation Waiver for Warp Corps' Youth Outreach Programming, you are consenting to a Release of Information (ROI) for Warp Corps to provide any anonymous data to the McHenry County Mental Health Board. You do not need to accept to receive services and you may revoke at any time. If you have any further questions please reach out to us at (815) 985-6256

I accept

I decline

Parent/Guardian Signature *

First Name

Last Name

Date *

This waiver is valid for one (1) year from today, unless noted.

MM

DD

YYYY