Student Name *

First Name

Last Name

Student Phone Number *

(###)

###

####

Parent/Legal Guardian Name *

First Name

Last Name

Parent/Legal Guardian Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

(Will be contacted if parent/guardian is unavailable.)

First Name

Last Name

Emergency Contact Phone Number *

(Will be contacted if parent/guardian is unavailable.)

(###)

###

####

Race *

Black

Hispanic

Asian

Native American

Caucasian

Other

Health History *

(Check if child is subject to any of the following)

Asthma

Diabetes

Convulsions

Epilepsy

Hay Fever

Sickle Cell

Poison Ivy

Allergies

None

Other

Medical Consent *

In the event reasonable attempts to contact the above listed phone numbers have been unsuccessful, I hereby give my consent to the administration of emergency medical treatment by any licensed physician or dentist and to transport the child to any reasonably accessible hospital facility.

Yes, I consent.

No, I do not consent.

Permission & Waiver for Participation *

I, the parent or legal 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/legal 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.

Media Release *

As a parent or guardian of the minor mentioned above, I authorize the Collaborative Center for Social Innovation (“the Center”) to take and use visual/audio images of my child. Visual/audio images are any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips, accompanying written descriptions, and/or any other type of media now or hereafter known. The Center may use and/or authorize the use of my child’s video/audio images and/or my child’s name in any manner or media without notifying me -- such as but not limited to, websites, publications, presentations, exhibitions, broadcasts, advertisements and/or posters. I waive any right to inspect or approve the finished images, prints, or any electronic matter that may be used with them. I agree that all visual/audio images connected therewith are and shall remain the property of the Center. I release the Center, its employees, officers, trustees, administrators, successors and assigns from any claims, damages, or liabilities which I may ever have in connection with the taking of or use of my child’s visual/audio images and/or my child’s name. I have read this release before checking a box below. I understand its content and I freely accept its terms.

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 Media Release.

I do NOT accept the Media Release.