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: