2014 Re|Act Registration Form

Student Name __________________________________

Date of Birth (M/D/Y) __________________ M F

Please note any medical issue, allergy, or special need

Spotlight On Youth should be aware of (this information is
confidential and will ONLY be shared with staff directly
supervising your student).

Age (as of August 10, 2014) ________________________

______________________________________________
School ________________________________________
______________________________________________
Address _______________________________________

______________________________________________

City, State, ZIP __________________________________

Preferred clinic/hospital system _____________________
Home Phone ___________________________________
Primary Doctor __________________________________
Student Cell Phone ______________________________
Student Email ___________________________________

Please Read Carefully

Primary Parent Contact (circle): Mother/Father/Guardian

Spotlight On Youth will provide reasonable supervision of

students within its care and control. The supervision will be
consistent with the ages of the students. However,
Spotlight On Youth is not an insurer of the safety of the
students, nor can it supervise all movements of all students
at all times.

Name _________________________________________
Address (if different) ______________________________
Employer ______________________________________
Job Position/Title ________________________________
Primary Phone __________________________________
Work Phone ____________________________________
Email _________________________________________

Spotlight On Youth, its staff, and its volunteers do not

assume liability for medical expenses, except in the case of
reckless behavior or an intentional act of injury to a
student.
Please Sign
I give permission for my student to be transported to official
off-campus activities such as poster distribution and
promotional activities.

Emergency Contact
Name ______________________________ Date _______
Name _________________________________________

Day Phone _____________________________________

I give consent to Spotlight On Youth to use media images

of my student for publicity and marketing purposes for the
organization.

Evening Phone __________________________________

Name ______________________________ Date _______

Relationship ____________________________________