Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone *

emergency contact number

(###)

###

####

Parent Consent *

I give consent for my child to participate in the youth camp

Yes

Media Release *

I hereby grant permission for the Youth Empowerment Program to photograph, record, or otherwise capture my child, in connection with activities and events. I understand that these images or recordings may be used in promotional materials, social media, websites, or other public platforms. I acknowledge that no compensation will be provided and that I may withdraw consent at any time by providing written notice to Youth Empowerment Program

I consent

I do not consent