ImagineWorks Youth Volunteering Form
Youth Application for IW Membership (To Be Completed by Parent/Guardian)

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Youth Information
First Name *
M.I.
Last Name *
Gender
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Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Information
First Name *
M.I.
Last Name *
Mailing Address *
City *
State *
Zip Code *
Home Phone
Cell Phone *
Email Address *
Occupation
Employer
Emergency Contact #1 Name *
Emergency Contact #1 Phone Number *
Emergency Contact #2 Name
Emergency Contact #2 Phone Number
Consent
The youth identified above and parent/guardian understands In volunteering for ImagineWorks (IW), authorizing participation in activities and programs of ImagineWorks (IW) and to use its facilities, equipment, machinery, tools, and in addition to the payment of any fee or charge, I do hereby waive, release, and discharge IW and its officers, agents, employees, representative, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any actives sponsored by IW. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any those mentioned or others acting on their behalf or in any way arisen out of or connected with my participation in any actives hosted by IW or the use of any equipment provided by IW. By signing below I agree to this consent and release agreement.

Electronic Signature *
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