This event is completely FREE to participate

Middle and high school students, let’s celebrate the end of the first quarter with a Timeout and Check-In. Join your peers for a day focused on fun, wellness, and self-care. The event is free and food will be provided.

We are excited to have you attend the Teen Timeout: Let’s Check In on December 14,2024 at the Arlington Central Library

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STUDENT INFORMATION

Name*

First Last

Name you prefer to be called*

Phonetic pronunciation of your name*

Preferred pronouns*

Date of Birth (mm/dd/yyyy)*

Grade

Please enter a number from 1 to 12.

School Name

Lunch Preference*

Vegan

Vegetarian

Gluten-Free

No Restrictions

Email*

Phone*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

EMERGENCY CONTACT INFORMATION

Emergency contact name*

First Last

Emergency Contact Phone*

AGREEMENTS & WAIVERS

Waiver*

I understand that there are certain inherent risks involved in participating in the activities scheduled for the event including, but not limited to, the risk of theft or of damage to personal property and the risk of personal injury. In consideration of being granted permission to participate in the activities, use the facilities, and receive services at the event, including food service, I, on behalf of myself, my executors, administrators, heirs, next of kin, and successors, hereby covenant to hold harmless and indemnify the Center for Youth and Family Advocacy (CYFA) and all of its officers, departments, agencies, agents and employees from any and all claims, lessees, damages, injuries, fines, penalties and costs (including court costs and attorney’s fee), charges, liabilities, or exposures, however caused, resulting from arising out of or in any way connected to my or my family's participation in the programs I further accept that no accident or medical insurance is provided to participants by CYFA or its agents.

I hereby grant CYFA permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of CYFA and will not be returned. I hereby irrevocably authorize CYFA to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. I waive any right to inspect or approve the finished product wherein my likeness appears. I also waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge CYFA from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I have read, understand, and accept this Waiver, including its hold harmless, indemnification, and likeness waivers. I, by my signature, agree to its terms. I affirm that I am at least 18 years of age or, if I am under the age of 18 years, I have obtained the required consent of my parent/legal guardian as evidenced by their signature and acceptance here.

I agree

Student Signature*

Parent/ Guardian Signature*

How did you hear about us?*

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