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Universal Permission Form
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Step
1
of 5
Effective Dates: January 1, 2022 — December 31, 2024
I. YOUTH INFORMATION
Youth Name
*
First
Middle
Last
Nickname
School
*
Grade
*
Gender
*
Male
Female
Date of Birth
*
MM
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DD
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YYYY
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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1929
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1927
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Primary Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Secondary Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Youth Email
*
Email
Confirm Email
Youth Home Phone #
*
Youth Cell Phone #
*
II. PARENT/GUARDIAN INFORMATION
How Many Parent/Guardian Contacts?
*
1
2
3
4
#1 Parent/Guardian Name
*
First
Last
#1 Relationship
*
#1 Phone
*
#2 Parent/Guardian Name
*
First
Last
#2 Relationship
*
#2 Phone
*
#3 Parent/Guardian Name
*
First
Last
#3 Relationship
*
#3 Phone
*
#4 Parent/Guardian Name
*
First
Last
#4 Relationship
*
#4 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
*
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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 during the period of January 1, 2022 – December 31, 2022.
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
*
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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?
*
Yes
No
Medical Insurance Co.
*
Insurance Co. Phone #
*
Policy/Group ID#
*
Policy Holder's Name
*
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.
How Many Medications?
*
None
1
2
3
More than 3
1st Medication Name
*
i.e., Zyrtec
1st Med. Dose?
*
i.e., 5mg
1st Med. Treatment for?
*
i.e., seasonal allergies
1st Med. Dispensing Instructions?
*
i.e., Take one pill daily in the morning with food.
2nd Medication Name
*
i.e., Zyrtec
2nd Med. Dose?
*
i.e., 5mg
2nd Med. Treatment for?
*
i.e., seasonal allergies
2nd Med. Dispensing Instructions?
*
i.e., Take one pill daily in the morning with food.
3rd Medication Name
*
i.e., Zyrtec
3rd Med. Dose?
*
i.e., 5mg
3rd Med. Treatment for?
*
i.e., seasonal allergies
3rd Med. Dispensing Instructions?
*
i.e., Take one pill daily in the morning with food.
List All Medications
*
For each medication please list: 1. Medication Name, 2. Dose, 3. Treatment for, 4. Dispensing Instructions
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
*
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Youth/Mentee Participation Expectations
The following rules and guidelines are basic expectations for J100 youth and mentee participants:
NON-NEGOTIABLE RULES
Any participant failing to abide by these rules will be sent home immediately at personal/family expense.
No use of illicit drugs or alcohol.
Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions.
No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments).
Must be in assigned rooms by designated time.
Smoking and the use of tobacco products are not allowed to, from, or during any trip.
Will not break any American laws in the United States or any other country.
GUIDELINES FOR SUCCESS
Participants will be responsible for performing assigned tasks in a timely and cooperative manner.
Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times.
Participants will be respectful to the property of others.
Participants will avoid the use of foul language, cursing, or any speech (including “humor”) which puts down, makes fun of, or stereotypes other persons or groups.
Youth Participant’s Statement:
By signing this form, I pledge to respect others during J100 activities by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file.
Youth Signature
*
Clear Signature
Date Youth Signature
*
Parent/Guardian Statement:
By signing this form, I agree to support the rules and expectations of the J100 printed above, and will accept responsibility for the payment of my child’s return transportation should s/he break one of the non-negotiable rules.
Parent/Guardian Signature
*
Clear Signature
Date Parent/Guarian Signature
*
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J100 Photo Release Form for Children and Youth
I agree that the J100 may photograph and record my child/dependent’s likeness and activities (images) during J100 activities. I grant the following rights to the J100: permission to use and re-use, publish and re-publish, and modify or alter the image(s) taken during the shoot. Use of the images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the J100 website and on the Internet, and worldwide in perpetuity for the purposes stated above.
I waive my right to inspect or approve any editorial text or copy that is used in connection with the images and release and discharge the J100 from any and all claims arising out of use of the images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.
I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.
Name of person completing the form
*
First
Last
Contact Phone #
*
Email
*
Parent/Guardian Signature
*
Clear Signature
Include a clear head shot photo of the Youth
*
Click or drag a file to this area to upload.
Take a recent headshot photo of the youth for identification purposes. Must be head and shoulder at least 2” x 2 1/2”.
Submit Permission Form
