Contact Chicago Treasurer's Office | Treasurer Melissa Conyears-Ervin

Youth Summit Participation Waiver & Release Form

Event Date: Saturday, October 4, 2025

Event Time: 10:00 am – 3:00 pm CT

Event Location: UIC Forum, Chicago, IL

Student Name(Required)

First Last

Date of Birth(Required)

School/Organization (if applicable):

Parent/Guardian Name(Required)

First Last

Parent's Phone(Required)

Parent's Email(Required)

Emergency Contact (if different)

First Last

Emergency Contact Phone (if different)

Medical & Dietary Information

Do you have any allergies or dietary restrictions?(Required)

Yes

Do you have any medical conditions?(Required)

Yes

Please list any allergies or dietary restrictions:

Please list any medical conditions we should be aware of:

Liability Waiver

1. My child’s participation in the Event is voluntary. 2. The Office of the Chicago City Treasurer (CTO), its employees, agents, contractors, and volunteers are not responsible for personal injury, illness, loss, or damage to personal property arising from participation in the Event, except in cases of gross negligence or willful misconduct. 3. I release and hold harmless the CTO, its employees, contractors, partners, and volunteers from any liability, claims, or demands arising from my child’s participation.

Supervision & Dismissal

• My child will remain under the supervision of event staff, volunteers, and approved chaperones from check-in until 3:00 p.m.

• After 3:00 p.m., the CTO is not responsible for my child. I agree to pick up my child (or ensure my authorized representative does so) promptly at dismissal.

• My child will not be released to anyone other than myself or the individuals listed below:

Release Full Name 1 (if appicable)

First Last

Release Phone (if appicable)

Release Full Name 2 (if appicable)

First Last

Release Phone 2 (if appicable)

Code of Conduct

• My child agrees to follow all event rules and instructions from staff/chaperones.

• If my child engages in unsafe or disruptive behavior, I may be required to pick them up early.

BWTT Youth Waiver

Medical & Dietary Information

Liability Waiver

Supervision & Dismissal

Code of Conduct

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