TEEN CENTER PARENTAL CONSENT

I, the undersigned parent or legal guardian of the above named child, do hereby give my permission for the child
named above to participate in the activities identified above planned by COSA. I am aware of and consent to the
scope of the activity to be engaged in and mode of transportation being employed. I understand that participation
in COSA program activities requires an acceptance of risk. I am aware of and accept the risks associated with the
activity to be engaged in and the mode of transportation being used.

I certify that the indicated participant(s) is/are in good physical and mental health and has/have never been
declared medically ineligible for athletic competition. I further certify that the above mentioned participant(s)
has/have had no previous pre-existing medical condition or injury, listed as, but not limited to exercise induced
asthma, cardio or pulmonary (lung) disease, abnormal organ deficiencies, and head or neck injuries which may
limit playing abilities. I understand that participation in COSA program activities requires an acceptance of risk.
With my signature, on behalf of myself and the above named child I hereby waive, release and hold harmless the
sponsors, promoter and all other persons and entities associated with COSA programs and events from any and all
claims, demands, actions, causes of action, obligations, debts, damages, losses, liens, liabilities, costs, attorney
fees, debts and expenses of every kind and nature whatsoever, in law or in equity, known or unknown, fixed or
contingent, including any and all rights to subrogation therefore which arise out of, result from or are related to
the above-named child’s participation in the activities set forth herein.

If I cannot be reached in case of an emergency, I hereby and authorize COSA to contact 911 or a medical facility
or physician of their choice to provide proper treatment and that I will be responsible for all expenses arising out
of or related to such treatment. I hereby authorize and consent to any x-ray examination, anesthetic, medical
and/or surgical diagnosis or treatment and hospital care which is deemed necessary and is rendered under the
general or special supervision of any licensed physician or surgeon or the medical staff of an emergency medical
service provider or a licensed hospital, whether such examination, diagnosis, or treatment is rendered at the office
of the physician or surgeon or at the hospital. I understand that this medical authorization and consent is given (1)
in advance of any specific examination, diagnosis, treatment, or hospital care being required and (2) to authorize
COSA staff to consent to examinations, diagnosis, treatment, or hospital care which is deemed advisable by a
licensed physician or surgeon or the medical staff of an emergency medical service provider or a licensed
hospital.

Furthermore, I hereby grant full permission for all the foregoing to transport the above participant(s) upon
request; and to use the above participant(s) photograph in video tapes, publications, motion pictures, recordings,
or other records of events. I have read and fully understand the foregoing and certify and represent that, as
parent/guardian for the above child(ren), all registration and release information provided is true. I hereby
represent that I have authority to bind and sign on behalf of all parent/guardians of the above participant(s).

Enrollment: Enrollment is limited. Our hope is to have enough room for all teens wishing to
participate in in programs at COSA; however, we cannot always accommodate everyone. After
receiving your completed forms, TEEN Center staff will call to let you know if your child will be
participating in a class(es) and the date that they may begin.

Attendance: Students must attend program six-week programs weekly. Regular attendance is
mandatory. Teens are expected to stay for the entire duration of registered classes. If a student is absent,
written or verbal notification must be submitted or communicated to the ASP Staff the next program
day.

Student Pick-Up: Children participating in activities at the TEEN Center must be signed out by you
or someone designated on the registration form (designated person must be 16 years of age and on
registration forms). Your child must be picked up promptly at the end of the program. If your child
has not been picked up by the end of the program, site staff will try to contact you and/or those
individuals designated as emergency contacts.

Discipline: Participation in at activities at the TEEN Center is a privilege. A child must follow the
rules of the program. Disruptive or disrespectful behavior towards other students or staff is cause for
dismissal. We encourage you to discuss concerns about your child’s behavior with TEEN Center staff.

Parental Support: While COSA’s TEEN Center staff are committed and qualified, your help is needed
to make the program the very best it can be. You are an important partner in our program’s success,
and we look forward to your help with events and activities, tutoring, field trips and other projects.

Release Form for Statements and Photographs
COSA periodically uses photographs of program participants for local, regional or state publicity of the
After School Program. By my initials, I acknowledge receipt of this document and give permission for
COSA use of statements, written and verbal, made by me, and/or photographs of my child in any and
all corporate brochures, flyers or publicity documents published by COSA and its affiliates. If I do not
initial this statement my child can still be part of COSA’s TEEN Center programs.

Transportation
My child has permission to walk home from the TEEN Center; furthermore, I give permission for my
child to sign themselves out of the TEEN Center Program. (Please check and initial if appropriate)
Walk Home Picked Up

I have read and understand all of the information above on COSA’s TEEN Center Parent agreement
and I give permission for my child to attend the after school program. All of the information in my
child’s after school registration form and the after school emergency card is complete. I agree to follow
the rules of the program and to help my child understand and follow the rules.

If you agree with these terms, you may proceed to register to participate at the COSA TEEN Center.