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Raleigh Youth Summit Participant Registration Form

Fields marked with an asterisk (*) are required Participants must be 13-18 as of September 28, 2019

PARTICIPANT TYPE

PARTICIPANT NAME

PARTICIPANT DATE OF BIRTH

Full Address

T-SHIRT SIZE (ADULT SIZING)

DIETARY PREFERENCES (SELECT ALL THAT APPLY):

PARENT/GUARDIAN NAME

DOES THE PARTICIPANT TAKE OR HAVE ANY OF THE FOLLOWING? IF YES, PLEASE EXPLAIN.

IN CASE OF AN EMERGENCY (IF PARENTS CANNOT BE REACHED) CALL:

IN ORDER FOR YOUR CHILD TO PARTICIPATE IN THE YOUTH SUMMIT, YOU MUST REVIEW AND ACCEPT THE TERMS OF THE PARTICIPATION AGREEMENT BELOW.

THIS EVENT IS SPONSORED BY THE RALEIGH POLICE DEPARTMENT

Non-Discrimination Policy: The Raleigh Police Department does not discriminate on the basis of race, color, national origin, sex, religion, age, sexual orientation or disability in employment opportunities or the provision of services, programs or activities.  A participant alleging discrimination on the basis of any of the aforementioned areas may file a complaint with the Raleigh Police Internal Affairs Unit, the City of Raleigh ADA Coordinator Policy 100-43, or the Office of Equal Opportunities, U.S. Department of Interior, Washington, D.C., 20240. 
The Raleigh Police Department welcomes the participation of all individuals, including those with disabilities.  We are committed to compliance with the Americans with Disabilities Act and will provide reasonable accommodations to facilitate participation in this program.  To ensure that reasonable accommodations are in place, we ask that every effort be made to inform us of reasonable accommodation requests at least 2 weeks before the event by contacting April Adams at 919-996-1124 or youthandfamilyservices@raleighnc.gov. 

Raleigh Police Department Youth and Family Services Program Participation Agreement

I acknowledge every effort will be made to contact parents/guardians in the case of a medical emergency. If I cannot be reached, I authorize the City of Raleigh Program Staff to seek appropriate medical (physician, dentist, nurse etc.) care for the above participant.  I understand that only those medications which are medically necessary and cannot be scheduled outside the hours of the noted program will be given during the program.  I give permission for my child to be transported in vehicles provided by the City of Raleigh. Pictures may be taken of my child while participating in City activities and may be used for program publicity. WHEREAS, the undersigned has requested the use of services, equipment, or facilities belonging to or under the auspices of the City of Raleigh, North Carolina, and to engage in activities for the executive benefit of the undersigned; and WHEREAS, the City of Raleigh does not wish to be liable for any damages arising from the personal injury or property damage sustained thereby; Now, therefore, in consideration of the mutual promises and other good and valuable consideration, the undersigned does hereby for himself, his heirs, executor, employers, successors or administrator, and personal representatives: A.   Assume full responsibility for any personal injury or any damage to his/her personal property which may occur directly or indirectly in the course of the noted program. B.   Fully and forever release and discharge the City of Raleigh, its agents, officials and employees, from any and all claims, demands, damages, rights to action, or cause of action, present or future, resulting from or arising out of this activity.  C.   Agree that it is the intent of the undersigned that this release and indemnity agreement shall be in full force and effect any time after the execution hereof.  WHEREAS, The City of Raleigh Code of Ethics prohibits possession and/or use of alcoholic beverages and illegal drugs, and/or sexual interaction, or being present where individuals are partaking of any illegal substance or participating in sexual interaction, or any behavior that violates state or local laws, or City Ordinances, and WHEREAS, The City of Raleigh Code of Ethics demands that all members respect the property of others and the facilities in which the members visit. I, the undersigned, have carefully read the foregoing release, know the contents thereof and sign it as my own free act. Any infraction of the above will necessitate the participant’s parents being notified and participant sent home immediately upon discovery. I understand that my child will be immediately transported home after being dismissed from the activity for violation of the aforementioned Code of Ethics. 

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