[Sample Form - Specific
Activity]
YOUTH PARTICIPATION FORM[1]
_______________ Chapter/District -
SPEBSQSA, Inc.
Youth [Name]:
_____________________
Activity: _______________________
Date of Birth: __/__/__
_______________________________
SS# __________________
Location: _______________________
Parent/Guardian:
____________________
Date(s): ________________________
Supervisor(s) [Name(s)]:
___________________________________________
Consent and Agreement by
Parent/Guardian
I, am the parent or legal guardian of the
Youth named above. The Youth
desires and/or has applied to participate in the Activity referenced above. I acknowledge that I have received
a copy of the Youth Policy Statement of the Society for the Preservation and
Encouragement of Barber Shop Quartet Singing in America, Inc. (SPEBSQSA)
**[and the Youth Policy Statement of the ______________ Chapter/District]
[2],
have reviewed and understand the same, and have had the opportunity to discuss
the same with persons responsible for the Activity. I have also carefully reviewed and
discussed the Policy Statement(s) with the Youth, particularly his/her
obligations and responsibilities as a participant in the Activity. I understand that participation by the
Youth is conditioned upon the consent, agreements, and other provisions
contained in this document.
I hereby consent to the Youth participating
in the Activity. I hereby designate
the Supervisor(s) named above (if other than the undersigned Parent/Guardian) to
supervise the conduct and activities of the Youth as a participant in the
Activity, including (but not limited to) participation in any associated
travel. I hereby grant to such
Supervisor(s) my permission, full authority and responsibility, in my place and
stead as a parent, to supervise the Youth as fully and completely as I might do
if I were personally present, as deemed necessary and appropriate in the
reasonable judgment of such Supervisor(s).
I understand and agree that the failure of the Youth to accept and comply
with such supervision, and/or the failure of such Supervisor(s) to provide
effective supervision of the Youth, may be grounds for the denial or immediate
termination of the Youth's participation in the Activity. I understand and agree that if any
Chapter, District or SPEBSQSA member provides such supervision, such member will
be performing that function in his individual and personal capacity, and not as
an agent or representative of the Chapter, District or
SPEBSQSA.
I accept full responsibility for all actions
of the Youth and such Supervisor(s) during or arising out of the Youth's
participation in the Activity. In
the event of any medical emergency involving the Youth, I further hereby
authorize such Supervisor(s) to obtain, provide, give consent, or furnish
authorization for, any necessary emergency medical services or treatment to the
Youth, including (but not limited to) surgical procedures which may be
recommended by a physician, it being my desire that the Youth be provided with
such emergency medical services or treatment as soon as reasonably possible,
after a need arises.
____________________________________(Signature)
Parent/Guardian
[Printed Name]:
_______________________________
DATE:_______________
Youth [Name]: _____________________ Date of Birth:
__/__/__ SS# __________
Activity:
_______________________________________________________
Location: _________________________ Date(s):
___________________
Supervisor(s) [Name(s)]:
__________________________________________
Acceptance of Responsibility by
Supervisor(s)
I, the Supervisor (s) named and designated above, hereby
accept responsibility for, and agree to perform, the supervision of the conduct
and actions of the Youth as a participant in the Activity. I understand that my responsibility
shall cover all aspects of the Youth's participation in the Activity, including
(but not limited to) participation in any associated travel. I agree that my responsibility shall
continue for the entire duration of the Activity, or until I rescind this
Acceptance by written notice to the Chapter, District, or SPEBSQSA officer (or
designated representative) in charge of the Activity. I understand that my failure to provide
effective supervision of the Youth, or my rescission of this Acceptance, may be
grounds for the denial or immediate termination of the Youth's participation in
the Activity. [If more than one
Supervisor is named, the foregoing statements and agreements are separately made
by, and shall separately apply to, each.]
____________________________________(Signature)
____________________________________(Signature)
Supervisor(s)
[Printed Name(s)]:
______________________________
______________________________
DATE:_______________
Acknowledgment by
Youth
I, the Youth named above, understand that my
participation in the Activity is conditioned upon the supervision of my conduct
and actions by the Supervisor(s) named above. I understand that my failure to accept
and comply with such supervision, or the failure of such Supervisor(s) to
provide the same, may result in the denial or immediate termination of my
participation in the Activity.
____________________________________(Signature)
Youth
[Printed Name]:
_______________________________
DATE:_______________
Youth Policy Activity
Form.doc
11/2/02