WIOA Pre-Employment 2017 Youth Summer Program Agreement Form Youth Name Address Street Address City State / Province / Region ZIP / Postal Code Youth Cell PhoneParent Contact NumberExplain why you would like your youth to participate in the summer youth program. What skills would you like them to work on? What would you like them to be able to experience?Below are some questions to help staff members better serve your youth. Information provided will be used to help us plan and organize classes.1. Are you able to provide transportation to and from activities?YesNo2. How comfortable is your youth with the UTA? (Answer Yes or No) Able to ride the UTA alone? Yes No Needs help? Yes No Able to transfer buses? Yes No Needs training? Yes No Do you want training? Yes No 3. Is your student able to recognize dollar amounts? Yes No Able to count change? Yes No 4. How long can your student go between bathroom breaks? Can your student use the bathroom independently? Yes No 5. If your student needs a personal assistant, can you provide one? 6. Does your student require special dietary needs? 7. Does your youth have any physical limitation or needs (Answer Yes or No) o Requires Wheel Chair or Walker Yes No Is fatigued easily Yes No Cannot go into the water Yes No Will require medication to be carried on person Yes No Can you student administer medication independently? Yes No Occasionally has seizures Yes No Other (please Explain) Yes No Explanation8. Other comments or concerns or accommodations your student will need to participate? 2017 Youth Summer Program Agreement FormI hereby give permission/agree for the above listed to participate in Ability 1st Utah’s Youth Summer Program. With this fully signed permission form, I hereby release and discharge Ability 1st Utah and its employees from all liability, claims, and/or demands for property damage and personal injury which may arise from an accident or injury while attending activities in the summer program or in being transported to and from these activities. Yes No I agree to authorize Ability 1st Utah to take and utilize photographs, videos, and/or other audio-visual materials for its use. These materials will be used for public awareness, public relations, and fundraising. I also understand that I will not be compensated monetarily or otherwise for use by Ability 1st Utah. Yes No Consumer of legal age & status signature: (Type Name) Date MM slash DD slash YYYY Parent/guardian signature: (Type Name) Date MM slash DD slash YYYY In case of an emergency I can be contacted at the following number:Secondary emergency contact and number: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.