Release and Permission Form

Please read the following and check yes or no.

I give permission for my child to participate in Take a Break.
I agree to read the parent manual and support the policies stated in it to the best of my ability.
In the event that my child is injured I give permissionforTake a Break staff to call a physician, ambulance or dentist to treat my child, if necessary. I understand that a concentrated effort will be made to contact me, another guardian or emergency contact. I understand that we and not the YWCA Lincoln will accept this expense.
I give permission for my child to attend field trips with TAB program that would include walking in the community.
I give permission for my child's, my families, and my own image to be used in pictures, digital images, and video for the purposes of promoting the TAKE A Break Program on social media, grant information, or other uses deemed necessary by YWCA of Lincoln and partnering organizations.
First Name
Last Name
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