AUSTIN17HOUSE WAIVER

 

At Austin17House we offer a number of activities and opportunities for our youth to have FUN!

Safety is a high priority of ours so please fill out the below form and submit prior to your youth visiting the facility. 

If you have any questions: Contact Director Lindsey Messina at 603 - 418 - 5864

Youth Name *
Youth Name
Date of Birth *
Date of Birth
i.e. food, medications, environmental, etc.
Care for your child *
In the case my child is injured, I give Austin17House permission to care for my child
If yes
Parent: *
Parent:
Social Media *
Social media (e.g., Facebook, Twitter) is a powerful communications tool. Austin17House (“AH”) expects all volunteers and partnered organizations abide by its social media policy in all their communications on any social media site. See button below** Do you give Austin17House permission to post and use photos of your child for marketing materials and social media accounts?