Please print, have signed, and bring to the event for each participant under the age of 18! YOUTH AND SHELTER SERVICES, INC. AMES, IOWA Activity Consent and Release We give our consent to allow _____________________ to participate in activities sponsored by Youth and Shelter Services. It is our understanding that we will be notified by phone/mail of the dates and details of any of these activities. It is our understanding that the child will be under the supervision of a staff member of Youth & Shelter Services, Inc., for the duration of the activity. I release Youth and Shelter Services, Inc., its agents and employees, from all actions, causes of action, damages, claims, or demands which I, my heirs, executors, administrators, or assigns may have against it, and other above described parties for all personal injuries known or unknown which the child has or may incur by participating in the above described activity. I have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance. Date: Yes ( ) No ( ) We have family insurance that will cover any injury that occurs in the program. Insurance Company: ________________________________________ ____________________________________ __________________________________ Parent/Guardian Parent/Guardian Referral Source Agreement #30c Revised 2/2/95/SB