UCASA TEEN CENTER PROGRAM

United Communities Against Substance Abuse

REGISTRATION/RELEASE FORM
  Today's Date:  ____________     Please Print ALL information on this form legibly. 
Please enroll my son/daughter in the UCASA TEEN CENTER PROGRAM.
____________________________________________ _______ ______ ____/____/____ M/F

Member Name

 Grade Age Date of Birth Sex
_______________________________________________________________ _______________ _____ ________

Member's Mailing Address

 City State Zip
  Email Address:  _______________________________________________
_________________________________ ___________________________________________________________
Mother's Name Mother's Address (If different from Member)
_________________________________ __________________________________________________________
Father's Name Father's Address (If different from Member)

_____________________________

 ______________________________ ____________________________
Member's Phone Mother's Phone Father's Phone
_____________________________ ______________________________ ____________________________
Emergency Contact Relationship Phone
____________________________________________________________________________________________
Medications or Illnesses we should be aware of.

  Please read BEFORE signing:

       I, the undersigned, being the parent or guardian of the above named student of the Windsor Central School District, acknowledge that the UCASA Teen Center Program does not provide medical or accident insurance for the participants in this program.  In consideration of my son/daughter being allowed to participate in the above program, I accept FULL RESPONSIBILITY for insurance coverage for his/her participation, as well as for his/her conduct while participation in the program.  Further, I assume all risks and hazards incidental to such participation, and I do hereby waive, release, absolve, indemnify and agree to hold harmless the UCASA Teen Center Program, its members, and volunteers from any and all liability, claims, demands, cause or causes of action of any and all claims that may arise out of my son/daughter's participation in the program.

       Furthermore, I the parent or guardian of the above named member have read the UCASA rules as put forth by the UCASA   Teen Center Program and agree to abide by them.
______________ ______________________________________________________________________________
Date Parent or Guardian Signature

       I, the above named member, have read the Member Rules and Responsibilities as set down by the UCASA Teen Center Program and agree to abide by them.
______________ ______________________________________________________________________________
Date Member Signature

UCASA RULES