Lytehouse Online Video Permissions

Student Information

Student's Name

First NameLast Name

Email to send the meeting invite to

example@example.com

Parent Email

example@example.com

Birth Date

MonthDayYear

Current Grade

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

Media Information

Plese read all information below carefully, as this pertains to providing permission for your student to interact with our leaders and their peers via online video platform.

Is the student experiencing any concerns that would make this environment problematic for them?

I grant my student permission to turn on their video camera during this gathering.

YesNo

Does your student have access to a device (phone, computer, etc) that they can use for this gathering?

Do we have permission to post photos of your child in our Lytehouse social media?

YesNo

Do we have permission to follow your students & connect with them through their social media accounts?

YesNo

Informed Consent and Acknowledgement

I hereby consent to the participation of my/our child(ren) in this supervised activity.

I acknowledge that online meetings like these are hosted by (no less than two) adults who have been trained in protection proceedures, and the interactions will be recorded for my students protection.

I acknowledge that my student may interact in this gathering with the use of their device video (provided my consent above), audio, and that other participants and leaders will be able to see/hear my student and whatever of their background/home is in view/audio of the camera.

While every precaution is taken for the safety and good health, some activities carry with them the inherent risk of online interactions.

I/we, named below, undertake and agree to indemnify and hold blameless Pentecostal Assemblies of Newfoundland and Labrador, its personnel, its leaders and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Pentecostal Assemblies of Newfoundland and Labrador. This consent and authorization is effective only when participating in events of Pentecostal Assemblies of Newfoundland and Labrador.

I aknowledge that my student may be removed from this opportunity if their behaviour in this envronment is offensive, or harming to themselves or others.

I have read, understood and agree with above.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

LYM Online Student Registration