2022 QCamp Registration Form

Name *

First Name Last Name

Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email *

example@example.com

Phone Number (Include a number that would be okay to call in regards to the camp.) *

Area Code Phone Number

Age *

School *

Emergency Contact (Parent/Guardian/Caregiver) *

First Name Last Name

Phone Number of Emergency Contact *

Area Code Phone Number

QCamp will run from 12:00p – 4:00p daily from Wednesday, June 22 – Friday, June 24, at the UAY Youth Center in downtown Iowa City (355 Iowa Avenue).

I will attend all three days of camp. I will attend Day 1, Wednesday, June 22 – Community Day. I will attend Day 2, Thursday, June 23 – Self-Care Day. I will attend Day 3, Friday, June 24 – Beach Day.

How did you find out about UAY's QCamp

School UAY Facebook

Media Release

UAY programming often involves artwork made by youth and photos taken of the program in action. If the opportunity becomes available, we would like your permission to use your photo or artwork in promotional material for the program (including UAY's website) or in community art shows, interviews, or press conferences.

This consent does not allow UAY to release confidential information or discuss counseling services your family or child may have received.

1. I hereby grant to United Action for Youth, its agents, and others working for it (the “licensed parties”) the absolute right and permission to use, publish and broadcast my voice recording, name, picture, likeness, or creative works created by me (including, but not limited to, visual, musical or performance art) or any material based upon or derived therefrom (the “Materials”), in any manner or media whatsoever for purposes of advertising, promoting and publicizing United Action for Youth.

2. I shall have no right of prior approval, no claim to compensation, and no claim (including, without limitation, claims based upon invasion of privacy, defamation, or right of publicity) arising out of any use, alteration, distortion, or illusionary effect or use in any materials.

3. I retain the copyright in and to all the Materials.

4. If I am executing this Consent on behalf of my minor child, I further consent to participation by my child in interviews and press conferences.

Can UAY use photos of you from the event on Social Media and other marketing materials?

Yes No

Date *

Date

Parent/Guardian Name *

First Name Last Name

On June 24th, UAY would like permission to transport you your child from the United Action for Youth Center to Kent Park, located at, 2048 US-6 NW, Oxford, IA 52322. The participants will meet at UAY at 12pm and we will return by 4pm. Teen will need to be picked up or have a plan to get home by 7pm when Hangout closes.

I give my permission for my child to receive a ride from UAY staff to attend the UAY fieldtrip. UAY is not responsible for picking up and/or returning my child to his/her/their home. In the event that my child is injured while receiving a ride from UAY staff, I waive and release each and every member of the UAY Board of Directors, staff and volunteers from any claim or liability as a result of any injury that might be sustained by my child.

I give UAY permission to transport my child *

Parent/Guardian Signature (use finger or touchpad) *

Clear

2022 QCamp Youth Registration