Participant's Primary Care-Givers

Adults email addresses

Note: Communication about youth events will often be done by email. Please list emails that you check on a regular basis.

Barnes & Sons has a website where photos and videos from events are periodically published. It’s policy that photos of children are never published with names or other identifying information. Initial one:

Yes, you can use pictures and videos of my child. I hereby grant Barnes & Sons the permission to use my child’s likeness in photographs, video, and other media in all of its publications, including bulletin boards and website entries. I waive any right to royalties or other compensation arising or related to the use of the photographs or videos.

No, please do not print or publish photos or videos of my child online or in event-related publications.

“I/We hereby grant permission for my/our child to be a member of Barnes & Sons Mentoring Program and to participate in activities. I recognize responsible behavior is mandated at Barnes and Sons, Therefore, I/we agree that if this child engages in behavior which, in the judgment of the adult leaders, is not in the best interest of the trip or event, our/my child or any member of the group may, therefore, be sent home. I/We will assume full legal and financial responsibilities for such a return trip.”

“I/We hereby release from any liability Barnes and Sons and all of its personnel, employees, adult leaders and representatives from any claims for unintended or unexpected accidents which might occur during participation in youth events or traveling to or from said events. In granting this permission and release, I/We specifically recognize that my child may from time to time be transported to events by private vehicles operated by advisors or volunteers not as agents, staff, employees or representatives. In such regard, I/We specifically release and will hold harmless Barnes & Sons and their officers, employees, agents, staff and representatives from any and all liability which may arise as a result of such transportation whether or not organized by Barnes & Sons”

Name of Parent / Guardian

Address

Doctor's Name

Does this participant have any physical, psychiatric, emotional or behavioral conditions of which Barnes & Sons should be aware? (Please use the back of this form or an additional page if necessary)

Restrictions on activities

Regularly prescribed medications and doses

Allergies or special diet

The following authorization empowers Barnes & Sons adult leaders to take whatever steps they deem necessary to insure the well being of my child should a medical emergency occur during any meeting/activity. Every attempt will be made to contact the child’s care-givers and/or emergency contact provided. I further grant permission to participate in all activities and trips that are not noted in the restrictions area.

I, do hereby authorize Barnes & Sons adult staff to take necessary emergency measures in the treatment of (participant):if needed. My child is in good physical health and does not have any conditions or disabilities which may be aggravated except as noted on this form. If I cannot be reached in an emergency, I hereby the authorize the physician selected by Barnes & Sons to hospitalize, secure proper treatment for, and order injections, anesthesia and surgery for my child named above.

has my permission to go on all field trips and to all events with Barnes & Sons unless I specify otherwise in writing.