Universal Permission Form

Step 1 of 5

Effective Dates:January 1, 2025 – December 31, 2025.

I. YOUTH INFORMATION

Youth Name *

First

Middle

Last

Nickname

School *

Grade *

Gender *

Date of Birth *

Primary Address *

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Address

Address Line 1

Address Line 2

City

State

Zip Code

Youth Email *

Confirm Email

Youth Home Phone # *

Youth Cell Phone # *

II. PARENT/GUARDIAN INFORMATION

How Many Parent/Guardian Contacts? *

#1 Parent/Guardian Name *

First

Last

#1 Relationship *

#1 Phone *

III. EMERGENCY CONTACTS

Emergency Contact Name #1 *

First

Last

Em. #1 Relation *

Em. Phone #1 *

Emergency Contact Name #2 *

First

Last

Em. #2 Relation *

Em. Phone #2 *

IV. PARENTAL CONSENT

Parental Consent *

I, the undersigned, do hereby give permission for my child to attend and participate in any 100 Black Men of Jacksonville, Inc. (J100) activities, events, and program meetings for 1 year from my signature date below.

LIABILITY RELEASE: In consideration of J100 allowing the Participant to participate in children/youth program meetings, activities, events, and trips I, the undersigned, do hereby release, forever discharge and agree to hold harmless executive leadership, directors, employees, members and volunteers (collectively herein the “J100” from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth activities, including trips away from the J100 facilities. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify the J100 for any liability sustained by the J100 as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by the J100. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

Name Of Youth Participant *

First

Last

Signature Of Youth Participant *

Clear Signature

Sign this form with your mouse or finger.

Name Of Parent/Guardian *

First

Last

Signature Of Parent/Guardian *

Clear Signature

Sign this form with your mouse or finger.

Signature Date *

V. MEDICAL INFORMATION

Primary Care Physician

Doctor's Name *

Name of Practice *

Doctor's Phone # *

Doctor's Fax # *

Last Tetanus Shot? *

Date

Time

Insurance Information

Does the youth have medical insurance? *

Medical Insurance Co. *

Medications

List all medications the youth will take during any youth trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult chaperone in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.

Over-The-Counter Medication Permission *

NO. Contact me or get medical help if my child has any minor medical concerns.
YES. I give permission for an adult chaperone to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.

Medical Conditions:
Please answer in detail if applicable or write N/A.

List any medical conditions (asthma, diabetes, epilepsy, etc.)
List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction.
Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult chaperones to know.

List Details of Medical Conditions *

Effective Dates:January 1, 2025 – December 31, 2025.

I. YOUTH INFORMATION

II. PARENT/GUARDIAN INFORMATION

III. EMERGENCY CONTACTS

IV. PARENTAL CONSENT

V. MEDICAL INFORMATION

Primary Care Physician

Insurance Information

Medications

Youth/Mentee Participation Expectations

J100 Photo Release Form for Children and Youth