Parental Consent Waiver | Uncommon Ground Initiative

Fields marked * are required.

Section 1

Teen's Information

Teen's Full Name *

Date of Birth *

Age *

Grade

School

Home Address

City

State / Zip

Section 2

Parent / Guardian Information

Your Full Name *

Relationship to Teen *

Phone Number *

Email Address *

Section 3

Emergency Contact

If you cannot be reached in an emergency, who should we contact?

Name *

Relationship

Phone Number *

Section 4

Medical Information

This information is kept confidential and only used in a medical emergency.

Doctor / Physician

Doctor's Phone

Health Insurance Provider

Policy Number

Allergies (if any)

Regular Medications

Anything else we should know?

Section 5

Photo & Video Consent

UGI may photograph or record events for social media, our website, and fundraising materials. Please select your preference.

Yes — I give permission for my teen to be photographed and/or recorded at UGI events. Images may be used publicly. No — I do not give permission. I understand UGI staff will be notified.

Section 6

Consent & Liability Waiver

Please read carefully before signing.

I, the undersigned parent or guardian, give permission for my teen to participate in Uncommon Ground Initiative programs. I understand that UGI programming is faith-informed and Christian in nature. I authorize UGI staff and volunteers to seek emergency medical care for my teen if I cannot be reached. I understand that UGI will make every reasonable effort to ensure my teen's safety but that participation involves inherent risk.

I voluntarily assume the risks associated with program participation and release Uncommon Ground Initiative, Inc., its officers, volunteers, and agents from liability for injury, illness, loss, or damage arising from participation, except in cases of gross negligence or willful misconduct.

I have read and agree to the consent and liability waiver above. *

Section 7

Signatures

Parent / Guardian Signature *

Sign with your finger or mouse in the box below.

Sign here

Teen Signature (if 16 or older — optional)

Teen may also sign below.

Sign here (optional)

✅

Waiver submitted.

We have received your completed Parental Consent Waiver. Your teen is cleared to attend their first UGI event once both forms are on file.

Complete Form 2 — Photo Release →

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Parental Consent & Participation Waiver