Membership Registration Form

Please print this form first and then complete it.

	2007 - 2008 Contact & Permission Form (PLEASE PRINT CLEARLY)
Today's Date: ______________
Member's Name: ________________________________________________ Sex: M F Address: ____________________________________ Birth Date: ______________ City: ______________________ State: _____ Zip: __________ County: ______________ Phone: _____________________ Voice TTY VP (Circle all that apply) Member's E-Mail Address: ___________________________________ School Attending: ___________________________ Grade: 3 4 5 6 7 8 9 10 11 12 Parent(s)' Name: (Mother's Name & email address) ___________________________________ (Father's Name & email address) ___________________________________
In case of emergency, who to contact?
1) ________________ Phone: __________________ Relationship: __________ 2) ________________ Phone: __________________ Relationship: __________ Your child's primary physician and phone number: Medical Insurance _________________ Policy Number _________________ If necessary, do you have a preference of which hospital you want your child to go to? Please list any allergies, special medication, limiting conditions, or restricted activities: ** NOTICE: DSC WILL NOT TREAT YOUR CHILD OTHER THAN WOUNDS THAT REQUIRE BAND-AIDS. WE WILL NOT GIVE YOUR CHILD ANY MEDICATION, INCLUDING ASPIRINS. IF YOUR CHILD IS ON MEDICATION, HE/SHE CAN BRING MEDICATION AND SHOULD BE ABLE TO TAKE THEM ON THEIR OWN. PLEASE PROVIDE A NOTE STATING WHAT THE MEDICATION IS AND THE REASON FOR TAKING IT.

Continue to the next section back to top

Parent's Permission: (Please circle)
YES NO *	PUBLICITY PERMISSION: I agree that my child's photograph may be used in any bulletins, promotional brochures, newspaper, videotapes, and/or news media for the purpose of promoting the DKTC and DSC services.

YES NO *	EMERGENCY TREATMENT PERMISSION: In the event reasonable attempts to contact me and the others at the above numbers are unsuccessful, I hereby give my consent for the administration of any emergency medical treatment for the health and well being of the child named in this application. I further agree not to hold the Deaf Services Center liable for any medical bills resulting from injuries that my child may incur during the DKTC events.

YES NO *	VAN/CAR RIDE PERMISSION: Deaf Youth Program offers its members limited transportation services to and from selected places. If the services are available, I authorize Deaf Services Center's Deaf Youth Program to provide this service to my child.

YES NO *	LIABILITY WAIVER: I understand the opportunity which has been given to me and my child to participate in Deaf Services Center's DKTC Program. When participating in these events, I understand that I waive and release all the rights, demands, and claims for damages against the organizers of these activities, the DSC officers, trustees, employees, volunteers, participants, and all sponsors for any/all personal or property injury which may happen to me and my child during these events.
I am the parent or legal guardian of the child named in this application. I give permission for the child to be involved with the Deaf Kids & Teens Club Program.
____________________________________________________ (Parents' signature & date) This permission form is valid for one year from the date signed above.

When completed, please send the form to:
Deaf Services Center, Inc.
Attn: DKTC Sign Up
5830 N. High Street
Worthington, Ohio 43085

For questions, contact:
Call: 614-841-1991 TTY/Voice
VP: 614-841-1991 or DSCColumbus.homeip.net
Fax: 614-841-4909
E-mail: DKTC95@dsc.org