New Heights Youth, Inc. Parental Consent Form 2019-20 Please do not hesistate to contact our Education Director, Denise Harding at DHarding@newheightsnyc.org if you have any questions. Student-Athlete Name * First Name Last Name Parental Consent * I, the undersigned, certify that I am the parent or legal guardian of my child. As such I grant permission New Heights Youth, Inc. regarding the following items: ● I do hereby grant permission for my child to participate fully in all New Heights programming and special events. ● I also grant permission for New Heights Youth, Inc. to use the images (photographs, video, interviews, etc.) of my child taken by New Heights staff or volunteers, media representatives, newspapers, and television reporters, photographers, special event staff or public relations personnel. Photographs, videos and interviews will only be used to promote the New Heights Youth Program. ● I give permission for my child’s school to release all academic records to New Heights Youth, Inc. ● I give my consent for my child to travel and otherwise participate in all trips with New Heights. ● I give permission for my child to eat meals or snacks in connection with the Program. ● I give my consent for my child to travel and otherwise participate in all trips with New Heights. ● I give permission for my child to eat meals or snacks provided by the Program. ● I give my consent to New Heights to seek medical care for my child should he/she need it. I agree to pay all of the costs (or use my insurance, if any) associated with the medical care that my child receives. I understand that New Heights will act in good faith to contact me before and after care is provided. ● I am fully aware that some Program activities can be dangerous and may result in serious injury. Knowing and understanding all possible risks and dangers, including those resulting from the COVID-19 pandemic, I hereby expressly and willingly allow my daughter/son’s participation in New Heights’ program activities. In consideration of my daughter/son’s participation, I hereby waive all claims or causes of action against New Heights, its officers, directors, employees, agents, and volunteers from all liability in connection therewith. Furthermore, I give any New Heights parent, faculty, and/or staff and volunteers present at the program permission to seek medical attention for my daughter/son in the event that she/he becomes injured. I AGREE to the Parental Consent and Commitment Requirements I DO NOT AGREE to the Parental Consent and Commitment Requirements Medical Information Please update if needed. If information is the same, skip to the signature line. Hospital / Clinic Preference Physician's Name Physician's Phone Number (###) ### #### Physician's Address Medications Being Taken Currently (if any) Insurance Company Policy Number Allergies/Special Health Considerations Please indicate NONE if no allergies/special health considerations Signature Your Name (person filling out this form) * Your Relationship to this Child * Today's Date * MM DD YYYY Thank you!
