Youth Permissions

YOUTH PERMISSIONS

This form pertains to the following youths (under 18 years old):

* Indicates required field

Name of Youth 1 *

First

Last

Age of Youth 1 *

Name of Youth 2 *

First

Last

Age of Youth 2 *

Name of Youth 3 *

First

Last

Age of Youth 3 *

Name of Youth 4 *

First

Last

Age of Youth 4 *

Note: Use a separate for for additional youths

Name of Responsible Party *

First

Last

Phone Number *

Email *

Notes to parents, guardians and youth members:

Club officials and local police reserve the right to deny admittance to any dance or club activity.
There are no re-entry privileges at any dance or club activity.
Any person found under the influence of and/or in possession of illegal substances will be ejected from any dance or club activity and turned over to the police.
Absolutely no smoking is permitted on the premises of any dance or club activity.

I agree to these stipulations *

YES NO

I give my permission for the above-mentioned youth(s) to join and participate in Rockin' Squares' dances and other club activities. *

(By typing name here acknowledges electronic signature)

Date Signed: *

Submit