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This form must be completed for each child
that attends the Purcellville Teen Center
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Child's Middle Initial
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Child's Last name
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Child's First Name
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City where child resides
on Teen Center night
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School
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Date of birth
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Grade
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We collect gender/ethnicity
information to ensure that
we are serving all sections
of our community
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By Submitting this Form, I acknowledge and agree to the following:
- I am the Parent/Guardian of the child named on this Form
- I accept complete responsibility for the conduct of my child
while at the Teen Center
- I acknowledge that I have the opportunity to attend the Center
and supervise my child at any time, should I desire to do so
- I acknowledge that several hundred youth usually participate
at the Teen Center every Friday Night, and that incidents can
(sometimes do) happen
- I acknowledge that the Teen Center and/or the Press
occasionally takes photographs of the activities in the Teen
Center, and I agree for my child's photograph to be published
on this web-site and/or in the newspaper
- I acknowledge that no medical insurance, liability insurance,
or insurance of any kind is provided for any child by the Teen
Center
- I expressly hold harmless all persons, businesses, and
government organizations from any incident that may occur to
my child while participating at the Teen Center. This "hold
harmless" agreement includes (but is not limited to) all
members of the Teen Center Management Committee, all
volunteers, all rink staff, all transportation staff, the Town of
Purcellville, Loudoun County, and the Federal Government.
The agreement extends to all areas in and around the Teen
Center, and to the use of Teen Center transportation
Please do not send your child to the Teen Center unless you
complete this Agreement. If you decide to send your child anyway,
then we will consider that you have accepted the Agreement, and
that you are bound by its conditions
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Parent/Guardian Name
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Parent/Guardian Address
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Parent/Guardian City
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Parent/Guardian Email
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Parent/Guardian Tel #
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Emergency Tel Number (if no
answer at primary number)
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Press the Submit button to send this
Agreement to the Teen Center
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