In case of medical emergency, I hereby give permission to the physician selected by the leader in charge to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for myself/my child, as named on this form.  I certify that myself/my child is in good physical condition and is able to participate in the entire program, other than any activities listed as restricted above.

I give Northwestern Community Youth Center permission for myself/my child to take part in the Summer Park Program event held in July 2025.  I further agree to hold Northwestern Community Youth Center and its agents harmless to indemnify them against all losses, liabilities, claims, or expenses including fines, penalties, and attorney’s fees due to injury or alleged injury to myself/my child incurred in connection of the operation of the event.  I also assume the responsibility of any damages to the facility myself/my child is assigned to the was caused by myself/my child.

I give Northwestern Community Youth Center permission to use pictures and video of myself/my child in multi-media.  I understand that NCYC will use discretion and sound judgement in taking pictures and video of myself/my child in the above stated manner.

By submitting this form I approve that I have read and agree to all of the above.