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SY Learning Hub Registration

Participant Registration/Consent Form

Guardian: This form MUST be filled out by a custodial parent or legal guardian.
A separate application must be completed for each child you want to register.
Call Solar Youth Learning Hub Coordinator Kim Dickey with questions at (203) 747-8289.
Program
Solar Youth Program your child is enrolling in:
Child’s Information
First Name
Last Name
Race/Ethnicity
Solar Youth History
Has your child been in Solar Youth before?
Guardian Information
First Name
Last Name
Only fill in if different than Child's
(to be invited to the Solar Youth Facebook Page)
(to be invited to the Solar Youth Twitter Feed)
Emergency Contact Information
First Name
Last Name
First Name
Last Name
Arrival and Dismissal
How will your child get to/leave from the Hub?

We will follow up with a more detailed Arrival/Dismissal Form after initial registration.

Financial Information (requested by our funders)
Household Income (please check one)
Does your child received free or reduced price lunch at school?
Are you a Housing Authority of New Haven (HANH)/ Elm City Communities Resident?
(This includes any subsided housing, including Section 8)
Medical History

This information is used to ensure your child’s wellbeing and does not affect acceptance into program

Does Child have Asthma?
If yes, does child use an inhaler?
Breathing Machine?
Does Child have any known allergies?
Epi-Pen Carrier?
Does child take any medication?
Does child have
(We will be in touch for more details)
Consent and Liability Release

By signing below, I (legal guardian) give permission for my child to participate in a Solar Youth program. As a condition of participation in the program, I hereby agree, on behalf of myself and the Participant, as follows:

I am the parent and/or legal guardian of the Participant.

I understand that participation in Solar Youth involves trips to locations within and outside the City of New Haven, and I give permission for the Participant to attend all such trips during the duration of the program.

I forever release, discharge, waive, and covenant not to sue Solar Youth, its officers, directors, employees, agents, volunteers, contractors, predecessors, successors and assigns (collectively “Releasees”) for any liability, claim, damage, action, cause of action, loss, cost, or expense (including attorneys’ fees) of any nature whatsoever arising out of or relating to any loss, damage, personal injury, or death sustained by the Participant while participating in a Solar Youth program, whether on or off Solar Youth’s premises, or travelling to or from Solar Youth’s premises, including but not limited to any loss, damage, personal injury, or death caused or alleged to be caused by the negligence or future negligence of the Participant or the Releasees.

I shall indemnify and hold harmless the Releasees from and against any liability, claim, damage, action, cause of action, loss, cost, or expense (including attorneys’ fees) of any nature whatsoever arising out of or related to any loss, damage, personal injury, or death, sustained by the Participant, or alleged to be caused by the Participant, while participating in a Solar Youth program, whether on or off Solar Youth’s premises, or travelling to or from Solar Youth’s premises, including but not limited to any loss, damage, personal injury, or death caused or alleged to be caused by the negligence or future negligence of the Participant or the Releasees.

If the Participant requires emergency or urgent medical care while participating in a Solar Youth program or travelling to or from a Solar Youth program I hereby authorize any agent, officer, volunteer or employee of Solar Youth, to act in loco parentis, to transport the Participant to a doctor or hospital, and to consent to emergency or urgent medical treatment, including but not limited to emergence surgery, for the Participant until I or another parent/legal guardian of the Participant can be contacted to give or withhold consent for such medical treatment. I assume the responsibility for all medical bills that may result from such services.

I give permission for photos, video or artwork of or by the Participant to be used for promotional material by Solar Youth.

I release the New Haven Public School District to give any and all educational records concerning my child to Solar Youth. I understand this information will be used to evaluate the academic performance and needs of my child.

This Consent and Liability Form shall be binding upon myself, the Participant, and our heirs, administrators, executors, personal representatives, and assigns.

Solar Youth programs are not licensed to provide child daycare services.

By submitting this form, I certify that I have read and reviewed this Consent and Liability Form, and understand all of the foregoing provisions.

First Name
Last Name

Our Impact Since 2000

  • Youth Served

    3500

  • Youth Service Projects Completed

    500

  • Teen Internships Offered

    600

  • Unique Youth Served Per Year

    150

Green Jobs - Westville Manor Spring 2017

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