Registration and Waiver

Please fill out the registration form and waiver for the retreat below. This can be scanned and/or emailed back to: 

beautifulyoubracelets@gmail.com

or mailed to:

The Pemi Youth Center
c/o Got Beauty?
111 Main Street
Plymouth NH
0346.

ANY QUESTIONS? Email us at beautifulyoubracelets@gmail.com

got beauty?

The Empowerment Retreat: Presented by The Pemi Youth Center and The BEA[YOU]TIFUL Project

Saturday June 7, 2014

CHECK IN TIME: 8:30-9:00AM

PICK UP TIME: 6:00 PM

 at the Pemi Youth Center, 111 Main Street Plymouth, New Hampshire

REGISTRATION FORM

Full name_____________________________________________

Age____ Date of Birth ____/____/_____

Parent/Guardian full name______________________________________

Full Address ______________________________________________________________________________________________________

Tel. # Home ____________________________

Work __________________________

Cell/Other _________________________________

E-mail:___________________________________

T-Shirt Size: ______________________________

Person to notify in emergency ___________________________________________________

Tel # ________________________________

Participant’s health insurance company_______________________________

Participant’s doctor's name_________________________________________

Player's doctor Tel.______________________________________

Medical Concerns/Allergies of Participant (if none please write none, if yes please describe) _________________________________________________________________________________________________________________

Any Additional Concerns

got beauty?

The Empowerment Retreat: Presented by The Pemi Youth Center and The BEA[YOU]TIFUL Project

Saturday June 7, 2014

CHECK IN TIME: 8:30-9:00AM

PICK UP TIME: 6:00 PM

 at the Pemi Youth Center, 111 Main Street Plymouth, New Hampshire

WAIVER / INDEMNIFICATION

Parent(s) or legal guardian must sign below before the participant is accepted to participate in the “got Beauty Empowerment Retreat” to be held at the Pemi Youth Center at 111 Main Street Plymouth, New Hampshire on Saturday June 7, 2014 (the “Retreat”): As parent/legal guardian of the child named herein, I hereby represent that the child has been examined by a pediatrician and is physically fit to participate in the Retreat at the Pemi Youth Center. I hereby accept all responsibility for and agree to pay any and all costs of medical treatment resulting from any injury suffered by my child as a result of his/her participation in the Retreat. I further agree to indemnify and hold harmless the Pemi Youth Center, the BEA[YO]TIFUL Project, and their respective directors, officers, employees, agents and representatives, from any and all liability, damage, or expense arising out of my child’s participation in the Retreat.

In the event that I cannot be reached in an emergency, I hereby give permission for a qualified Pemi Youth Center staff member, an emergency medical technician, a physician or staff member at a hospital, or any other qualified individual to administer care and provide any medical treatment deemed necessary for my child.

Signature of parent(s) or legal guardian:

_______________________________________________________________________

Date: ________________