Student Name *

First Name

Last Name

Guardian Name *

First Name

Last Name

Phone *

(###)

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Does this Student have permission to participate in Pleasantville Youth Initiative Activities during the 2019-2020 year? *

Yes

No

Photo Permissions: I accept that the participant's likeness may be used in any online or print publications or social media by Pleasantville Youth Initiative. *

We are careful about sharing pictures and videos, and are happy to remove them at a parent's request.

YES, I accept and give my consent.

NO, I do NOT give my consent.

Emergency Contact *

We will contact this person only if you cannot be reached.

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

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