2. First Name*
3. Last Name*
5. Email Address*
6. Phone Number*
8. Participant is the same as above

   1. Yes
10. Participant First Name
11. Participant Last Name
13. Youth Phone*
14. Youth Email*
16. Reply Email
17. Date of Birth**
    Date of Birth*
18. Ethnicity:

    1. Hispanic or Latino
    2. White or Caucasian
    3. Black or African American
    4. American Indian or Alaskan Native
    5. Asian
    6. Prefer not to say
20. School
22. Grade:*

    1. 5TH
    2. 6TH
    3. 7TH
    4. 8TH

    1. 9TH
    2. 10TH
    3. 11TH
    4. 12TH
23. How did you hear about this program? Please place a to which category (or categories) apply to you:*

    1. Postcard/Direct Mailing
    2. Social Media
    3. School
    4. Town’s Website
    5. Email
25. Mailing Address
    Street, City, State, Zip
27. Emergency Contact Name*
29. The following have permission to pick up my child:*
30. Food Allergies or Other Health Concerns:*
32. I give permission for my child (ren)**

    1. I agree - Open Mic Night (s)

    To attend the Town of Southampton Youth Bureau’s Open Mic Night programs at Hampton Coffee Company in Hampton Bays - Friday, October 24, 6:00 PM – 8:00 PM and/or  at Nice Place Coffee - Friday, November 14, 6:00 PM – 8:00 PM. I hereby shall release liability, waive any claims against, indemnify, defend and hold harmless the Town of Southampton, its officers, employees, contractors, agents and representatives from and against any and all demands, liabilities, losses, damages, expenses (including reasonable attorney’s fees) and judgments relating to or arising from my child’s participation in the Town of Southampton Youth Bureau’s Open Mic Night program. I certify that my child’s health and physical condition are appropriate for participation in these physical activities. In the event of a medical emergency and I cannot be reached, I authorize the Town of Southampton Youth Bureau staff to seek emergency medical treatment. I also consent to photographs and video being taken of my child, understanding they may be used for promotional purposes.”

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34. Submit

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