North Midland Family Center
Teen Program
Risk Waiver

North Midland Family Center Teen Program students will participate in activities both indoors and
outside, including running, jumping, dodge ball, horseback riding, and use of the computer/internet.
As a result, the teens will be exposed to weather conditions, natural hazards and program activities,
and some of these activities could potentially be harmful.  North Midland Family Center staff is
trained to keep the teens as safe as possible.  However, sometimes unfortunate accidents can happen.
If you teen has any physical limitations, medical or food allergies, or you do not want them to
participate in a specific activity, please notify us in writing.  By signing this form you are confirming
that you understand the hazards inherent in the recreational activities and specifically agree that
your child may participate in the program and activities.

I give North Midland Family Center permission to take my child's picture and use it for promotional
purposes for the Teen Program and events at North Midland Family Center.

_____  I give my child permission to use NMFC computers and internet.

_____  I do not want my child to use NMFC computers and internet.

By signing this form, you also give permission to North Midland Family Center to secure
emergency medical and/or emergency surgical treatment if necessary for the named minor
child while in the care of North Midland Family Center.  Every effort will be made to contact
the parent or guardian if medical attention is needed.

_________________________________
 Child's Name

_________________________________
 Parent's Name

_________________________________                            __________________
 Parent's Signature                                                                    Date

Emergency Contacts:

1. _______________________________                            __________________
    Name                                                                                    Home Phone
_________________________________                            __________________
   Address                                                                                  Cell Phone

2. _______________________________                            __________________
    Name                                                                                     Home Phone
_________________________________                            __________________
    Address                                                                                  Cell Phone