Parent's/Guardian's name completing the form*

Parent/Guardian's Cell*

Teen's Name participating in the Teen Leadership Walk*

Teen's Cell*

I waive all liability of Lappin Foundation and host and program partners of the Teen Leadership Walk my child attends and all other participants for any injury suffered by my child or my family.*
Yes

Please list any allergies your teen has. Write “none” if your teen does not have any.*

Describe the treatment plan in the event of an allergic reaction.

Is there anything else you would like us to know about your child?

I understand the Teen Leadership Walk may be canceled due to inclement weather (because the Walk takes place outdoors), insufficient registration, or for any reason.*
Yes

I and my child have read and understand the Code of Conduct.*
Yes

I grant to Lappin Foundation, its representatives, and employees the right to take photographs of my child in connection with the Teen Leadership Walk. I authorize Lappin Foundation its assignees and transferees to copyright, use and publish the same in print and/or electronically. I agree that Lappin Foundation may use such photographs of my child with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I waive any right to royalties or other compensation arising from or related to the use of the photographs taken of my child.*
YesNo

Please email a copy of your teen’s insurance card (front and back) to Natasha@LappinFoundation.org or text it to her at 978-810-6399.

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