Buckhead Atlanta Teen Lock-In

As of 11:00 am. 8/8/12, Teen lock-in is registration is open. If you have paid and still need to submit the liability form, please continue. Please note that submitting a liability form without payment does not secure a spot for this event.

Metro Teen Lock-In

First Name

Last Name

Jack and Jill Teen or Guest

Jack and Jill TeenGuest

Guest, Please name the Jack and Jill teen who invited you.. Jack and Jill Teens, please list your chapter name.

Email Address

Street Address

City/State/Zip

Home phone

Cell Phone

Date of Birth

School and Grade 2012/13

Emergency Information

Emergency contact name and phone number

Please provide information for second point of contact

Physician's name

Physician's phone

Insurance Company

Insurance policy number

Allergies/Special Concerns

Emergency Treatment Consent

I authorize all medical and surgical treatment, X-ray, laboratory anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

yes no

Permission to Participate

I give permission for my child to participate in and/or ride the bus to the North Suburban Chapter of Jack and Jill of America, Inc. Metro Atlanta Teen Lock-In on Saturday, September 15, 2012, 8pm until Sunday, September 16, 2012 at 7am, at Ed Isakson Alpharetta Family YMCA, 3655 Preston Ridge Road, Alpharetta, GA 30005. Please enter your name.

Waiver of Liability

I also agree that the participation and/or the transportation of my child in/to this lock-in is done so at my child's own risk. The North Suburban Atlanta Chapter of Jack and Jill of America, Inc. volunteers shall not be liable for any claims, demands, injuries, damages, actions, or causes of action whatsoever to me or my child or my property or my child's property arising out of or connected with my child's being while in their care. I do hereby expressly forever release and discharge North Suburban Atlanta Chapter of Jack and Jill of America, Inc. volunteers from all such claims, demands, injuries, damages, actions, or causes of action, and from all acts of active or passive negligence. Please enter your name.

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North Suburban Atlanta Teen Lock-In

Metro Teen Lock-In