YLA

All information will be kept confidential.
The personal information contained on this form will be used to respond to medical and emergency situations.

First Name

Last Name

Age

Date of Birth

First Contact

Phone Number

Second Contact

Phone Number

Third Contact

Phone Number

Please provide detailed information, about your child’s allergies, medical/behavioural conditions.

1. Allergies

2. Medical/Behavioural Conditions

PLEASE NOTE:
STAFF ARE NOT RESPONSIBLE FOR THE ADMINISTRATION OF ANY MEDICATION
MEDICATION CARRIED BY CHILD MUST BE LABELLED WITH CHILD’S FIRST & LAST NAME.

3a. Medications carried/treatment required

3b. If medications are carried/treatment required, does your child know how to administer the medication (e.g. EPI pen, inhaler, etc.)

YES

PHOTOGRAPH & VIDEO CONSENT

I hereby grant permission for photographs and videos of my child, at the Youth Leadership Academy to be used by Youth Leadership Academy publications to display to promote its programs and services. I understand that those photos and videos may appear in print or electronic forms, and I agree that I am to receive no compensation for my child’s appearance. I also understand that I have no ownership rights to the photographs and videos whatsoever.

PARTICIPANT SPACE

Why do you want to be a part of the leadership Camp at YLA ?

What are some areas relating to leadership that you would like to personally develop, that you believe the program can assist with?

List any leadership roles you have previously undertaken/are currently in or looking to get into:

What leadership role in the community do you think you would like to assume?

CONTACT

Beirut, Lebanon -
Down Town,
Allenby Street,
LV Blg , 2nd Floor

P +961 1 957 605

M +961 81 080 875

E [email protected]

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