Section I: Student Information
Section II: Parent/Guardian Information
Section III: Emergency Contact Information
*must be someone different than parent/guardian named above
Section IV: Health Insurance Information
Section V: Parental Consent for Photography and Participation in Evaluation Studies
Please indicate if you give permission for your child to participate in the following activities:
*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote B-RELYT's mission and the mission of the LA Stem Collective.
Media Release of Information*
*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote B-RELYT's mission and the mission of the LA Stem Collective.
PARTICIPANT
In signing this Acknowledgement of Risk and Waiver of Liability I hereby acknowledge and represent that I am of legal age and have read this document in its entirety, understand it, and sign it voluntarily.
PARENT/GAURDIAN 1
Participants who are under 18 years of age, or not legally competent, must sign above, and also must obtain the signature of a parent or legal guardian below: I certify that I am the parent or legal guardian of the above-named participant. On behalf of myself and my spouse, partner, co-guardian or any other person who may represent the participant, I have read the above agreement, I understand its contents, assent to its terms and conditions, and sign it of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent’s participation, and I hereby give my consent to participation by my dependent, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend B-RELYT and all B-RELYT Staff Members from and against all claims, demands or suits that my dependent has or may have.
PARENT/GAURDIAN 2
Participants who are under 18 years of age, or not legally competent, must sign above, and also must obtain the signature of a parent or legal guardian below: I certify that I am the parent or legal guardian of the above-named participant. On behalf of myself and my spouse, partner, co-guardian or any other person who may represent the participant, I have read the above agreement, I understand its contents, assent to its terms and conditions, and sign it of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent’s participation, and I hereby give my consent to participation by my dependent, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend B-RELYT and all B-RELYT Staff Members from and against all claims, demands or suits that my dependent has or may have.
