Participant Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

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Checkbox *

I, the parent or guardian of the named participant listed on this form, do hereby give my permission to his or her participation in any or all activities of the Collaborative Center for Social Innovation's program for which the undersigned applied. To the best of my knowledge he or she is physically able to participate in said program. I further agree that the participant will abide by any and all rules, regulations, and procedures established by the Collaborative Center for Social Innovation or any other organization collaborating on the program. I do further release, absolve, indemnify, and hold harmless the Collaborative Center for Social Innovation, its organizers, sponsors, members, agents, supervisors, directors, and/or employees, or as a group, from any claims from any property damage, personal injury, and/or bodily injury which the named participant may suffer and to which the named participant and/or the legal guardian may be entitled and which said claim may arise during or be indirectly related to any or all activities of the Collaborative Center for Social Innovation, including transportation of the named participant to or from said activities whether or not the cause for the claim was through direct or indirect negligence of the Collaborative Center for Social Innovation, it's organizers, sponsors, members, agents, supervisors, directors, and/or employees.

I, the parent/guardian of the participant listed above, verify that I have read the agreement entirely and fully understand its meaning and content. This will serve as my acceptance of the Permission & Waiver for participation.

I do NOT accept the Permission & Waiver for participation. In checking this box, I understand that the participant will be unable to participate in the program.