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I give permission for my child to attend the Town of Southampton Youth Bureau’s Youth Court program from September 2021 - June 2022 at the Southampton Town Justice Court, 32 Jackson Ave and other locations TBA. I hereby shall release liability, waive any claims against, indemnify, defend and hold harmless the Town of
Southampton, its officers, employees, contractors, agents and representatives from and against any and all demands, liabilities,
losses, damages, expenses (including reasonable attorney’s fees) and judgments relating to or arising from my child’s participation
in the Town of Southampton Youth Bureau’s Youth Court program. I certify that my child’s health and physical condition are
appropriate for participation in these physical activities. I also understand that because of the current COVID-19 pandemic,
certain health and safety procedures outlined by NYS and the CDC will be implemented upon arrival & dismissal of my
child. I understand that they are important to ensure a safe environment for my child, other youth participants, and all
program staff involved. In the event of a medical emergency and I cannot be reached, I authorize the Town of Southampton
Youth Bureau staff to seek emergency medical treatment. I also consent to photographs being taken of my child, understanding
they may be used for promotional purposes.
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