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			<h1 class="article-header__title js-article-title js-page-title">CTeen Conejo Permissions/Liability Waiver</h1>
		
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<form class="userform-form" action="" method="post" enctype="multipart/form-data" name="form_6550584" id="6550584" accept-charset="utf-8"><input type="hidden" name="formID" value="6550584" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_16"><div id="cid_16" class="form-input-wide"> <div id="text_16" class="form-html"><p><span style="line-height:2;"><span style="font-size:14px;">Please complete the following form with a parent/guardian. You will only need to fill this out once. Once you have submitted this form click "yes" when RSVPing for individaul events to indicate that we have your form on file. </span></span></p>
</div> </div></li><li id="cid_17" class="form-input-wide"> <div class="form-header-group"><h2 id="header_17" class="form-header">Teen's Info</h2></div> </li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q1_fullName[first]" id="first_1" autocomplete="given-name" />  <label class="form-sub-label" for="first_1" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q1_fullName[last]" id="last_1" autocomplete="family-name" />  <label class="form-sub-label" for="last_1" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Hebrew Name </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q19_fullName19[first]" id="first_19" autocomplete="given-name" />  <label class="form-sub-label" for="first_19" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q19_fullName19[last]" id="last_19" autocomplete="family-name" />  <label class="form-sub-label" for="last_19" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Birth Date<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q18_birthDate[month]" id="input_18_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_18_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q18_birthDate[day]" id="input_18_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_18_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q18_birthDate[year]" id="input_18_year"><option></option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_18_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_4" name="q4_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q20_phoneNumber[full]" id="input_20_full" autocomplete="tel" />  <label class="form-sub-label" for="input_20_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> School<span class="form-required">*</span> </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_21" name="q21_input21" size="20" value="" /> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Grade<span class="form-required">*</span> </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_22" name="q22_input22" size="20" value="" /> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Home Address<span class="form-required">*</span> </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q23_address[addr_line1]" id="input_23_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_23_addr_line1" id="sublabel_23_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q23_address[addr_line2]" id="input_23_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_23_addr_line2" id="sublabel_23_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q23_address[city]" id="input_23_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_23_city" id="sublabel_23_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q23_address[state]" id="input_23_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_23_state" id="sublabel_23_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q23_address[postal]" id="input_23_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_23_postal" id="sublabel_23_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q23_address[country]" id="input_23_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option 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value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_23_country" id="sublabel_23_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Please let us know about any allergies or other medical concerns we should be aware of. </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <textarea id="input_25" class="form-textarea" name="q25_input25" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Who did you hear about CTeen from? </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_24" name="q24_input24" size="20" value="" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Are the natural mother and father of teen Jewish?*<span class="form-required">*</span> </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_26_0" name="q26_input26" value="Yes" /><label id="label_input_26_0" for="input_26_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_26_1" name="q26_input26" value="No" /><label id="label_input_26_1" for="input_26_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Have there been any conversions in the family?*<span class="form-required">*</span> </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_27_0" name="q27_input27" value="Yes" /><label id="label_input_27_0" for="input_27_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_27_1" name="q27_input27" value="No" /><label id="label_input_27_1" for="input_27_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_28" class="form-input-wide"> <div class="form-header-group"><h2 id="header_28" class="form-header">Parent/Guardian Info</h2></div> </li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Parent 1 Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q7_fullName7[first]" id="first_7" autocomplete="given-name" />  <label class="form-sub-label" for="first_7" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q7_fullName7[last]" id="last_7" autocomplete="family-name" />  <label class="form-sub-label" for="last_7" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Parent 1 E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_30" name="q30_email30" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Parent 1 Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q31_phoneNumber31[full]" id="input_31_full" autocomplete="tel" />  <label class="form-sub-label" for="input_31_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Parent 2 Full Name </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q29_fullName29[first]" id="first_29" autocomplete="given-name" />  <label class="form-sub-label" for="first_29" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q29_fullName29[last]" id="last_29" autocomplete="family-name" />  <label class="form-sub-label" for="last_29" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Parent 2 E-mail </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_32" name="q32_email32" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Parent 2 Phone Number </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q33_phoneNumber33[full]" id="input_33_full" autocomplete="tel" />  <label class="form-sub-label" for="input_33_full"><span> </span></label></span></div> </div></li><li id="cid_34" class="form-input-wide"> <div class="form-header-group"><h2 id="header_34" class="form-header">Permissions and Liability Waiver</h2></div> </li><li class="form-line" id="id_15"><div id="cid_15" class="form-input-wide"> <div id="text_15" class="form-html"><p><span style="font-size:14px;"><span style="line-height:2;">I/we give permission for the above mentioned teen to participate in the activities of <strong>CTeen Conejo 2025-2026</strong>. In consideration of the opportunity of my/our child to participate in the activities of CTeen Conejo, I/we release CTeen Conejo, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for any loss or injury to my/our child arising from my/our child’s participation in the activities; and I/we agree to indemnify and hold forever harmless CTeen Conejo, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for loss or injury to my/our child arising from activities of the CTeen Conejo. I/we understand that during events participants will be following current CDC guidelines in regards to Covid-19 pandemic; I/we will not hold CTeen Conejo responsible if above mentioned teen contracts Covid-19 while attending an event. As the parent(s) or legal guardian(s) of above mentioned teen participant, I/we give permission for CTeen Conejo, its agents, staff, and volunteers to obtain urgent or emergency medical care for my/our child, and I/we authorize health care providers to render such care as may be necessary. It is understood that reasonable efforts will be made to contact me/us prior to obtaining such care, but I/we authorize such care whether I/we are contacted or not, and I/we agree to be financially responsible for such care.</span></span></p>
</div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> I/ we have read the above statement and agree<span class="form-required">*</span> </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_35_0" name="q35_input35" value="Yes" /><label id="label_input_35_0" for="input_35_0"><span>Yes</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Emergency Contact<span class="form-required">*</span> </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q36_fullName36[first]" id="first_36" autocomplete="given-name" />  <label class="form-sub-label" for="first_36" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q36_fullName36[last]" id="last_36" autocomplete="family-name" />  <label class="form-sub-label" for="last_36" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q37_phoneNumber37[full]" id="input_37_full" autocomplete="tel" />  <label class="form-sub-label" for="input_37_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Relationship to teen<span class="form-required">*</span> </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_38" name="q38_input38" size="20" value="" /> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Teen's Signature<span class="form-required">*</span> </label></div><div id="cid_39" class="form-input"> <magen-file-drop-zone label="" name="q39_input39" id="input_39" class="form-upload" buttontext="Upload a File" required="required" additionaltext="Accepts .gif, .jpg, .jpeg, .png and .pdf" accept=".jpeg,.jpg,.gif,.png,.pdf" maxsize="20971520"> </magen-file-drop-zone> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Parent/ Guardian Signature<span class="form-required">*</span> </label></div><div id="cid_40" class="form-input"> <magen-file-drop-zone label="" name="q40_input40" id="input_40" class="form-upload" buttontext="Upload a File" required="required" additionaltext="Accepts .gif, .jpg, .jpeg, .png and .pdf" accept=".jpeg,.jpg,.gif,.png,.pdf" maxsize="20971520"> </magen-file-drop-zone> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center;" class="form-buttons-wrapper button-align-center"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="6550584" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "6550584-6550584";</script></form></div>
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