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Sign up for a Week Without Walls Program

Name

Pangalan

Email Address

Contact Number

School/Organisation

Paaralan/Organisasyon

Grade Level

Grado

Date of Birth

Kaarawan

Age

Edad

Address

Tirahan

Allergies (Please specify)

Pakitukoy kung mayroong mga allergies

Medical Conditions (Please specify)

Pakitukoy kung mayroong mga kondisyong medikal

Blood Type

Uri ng dugo

Name of Parent/Guardian/Emergency Contact

Pangalan ng Magulang / Tagapag-Alaga / o Emergency Contact

Cell Phone Number of Parent/Guardian/Emergency Contact

Cellphone Number ng Magulang / Tagapag-Alaga / Emergency Contact

In case of emergency if parent/guardian/Emergency Contact cannot be reached:

Sa pagkakataong may emergency at hindi makontak ang magulang/ tagapag-alaga / at emegency contact:

Name

Pangalan

Relationship to Child/Volunteer

Relasyon sa bata / volunteer

Home Phone Number

Cell Phone

Cell Phone Number

PHOTO/VIDEO RELEASE I (parent) do hereby give the Yellow Boat of Hope Foundation, their assigns and legal representative the irrevocable right to use photograph or video images of my child/me in all forms and media for education or other lawful purposes in its publications and displays. I waive my right to preview or approve the finished product, including written copy that may be created in connection therewith. I understand no fee will be paid to me now or in the future. I have read this release and understand its contents.

TRANSPORTATION RELEASE I give permission for my child to be transported to activities, riding in approved vehicles, or walking with staff to attend and participate in activities that are part of the program.

MEDICAL RELEASE I also give permission to the leaders of this program to secure emergency medical or surgical treatment for my child/for me if there is insufficient time to contact me and to secure routine, non-surgical medical care as needed.

WAIVER OF LIABILITY I agree to indemnify, release and hold harmless The Yellow Boat of Hope Foundation, and their respective officers, agents, employees, and volunteers from any and all costs, liabilities, expenses, claims, compensation, demands, or causes of action on account of any loss or damage to person or property of the aforementioned child/volunteer arising out of or in connection with his/her participation in the aforementioned Week Without Walls Programs and its activities.