Guardian Waiver Form
High School
Scholar Information
Contact ID
First Name
*
Middle Name
*
Last Name
*
Grade
*
9th
10th
11th
12th
Please do not put in your IPS Email address. Please only use a personal email. DO NOT USE THE SAME EMAIL FOR BOTH GUARDIAN AND STUDENT. If you don't have an email, please type out [yourfirstname]@[yourlastname].com. Thank you!
Scholar Email
*
Scholar Cell Phone
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
I prefer not to choose
Is the Scholar a 21st Century Scholar?
*
Yes
No
T-Shirt Size
*
XXS
XS
S
M
L
XL
XXL
XXXL
XXXXL
Ethnicity
*
African-American
Latino
Asian
Native American
Caucasian
Multi-ethnic
Other
I prefer not to say
Lunch Status
*
Free Lunch
Reduced Price Lunch
Free or Reduced Lunch
Neither
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Guardian Infomation
Guardian Contact ID
First Name (Guardian #1)
*
Last Name
*
Guardian Relationship to Scholar
*
Please Select
Parent
Grandparent
Aunt
Uncle
Other
Email
*
DO NOT USE THE SAME EMAIL FOR BOTH GUARDIAN AND STUDENT. If you don't have an email, please type out [yourfirstname]@[yourlastname].com. Thank you!
Guardian Cell Phone
*
Please enter a valid phone number.
Guardian Work Phone
*
Please enter a valid phone number.
First Name (Guardian #2)
Last Name
Email
DO NOT USE THE SAME EMAIL FOR BOTH GUARDIAN AND STUDENT. If you don't have an email, please type out [yourfirstname]@[yourlastname].com. Thank you
Guardian #2 Cell Phone
Please enter a valid phone number.
Optional Information
We ask for this information so that we can provide your student with this program at NO COST to you. Any information you’re willing to give us, helps us raise grant funds to keep this program at NO COST to you. Thank you!
Does your household have safe, stable, and secure housing?
*
Yes
No
Are you a female headed household?
*
Yes
No
Are you a single parent household?
*
Yes
No
How many people total are in your household?
*
What is your estimated household income?
*
$0-&16k
$16k-30k
$30k-45k
$45k-60k
$60k-80k
$80-90k
$90-97k+
$97+k
Does your scholar have access to reliable transportation?
*
Yes
No
Does your scholar have any children or dependents?
*
Yes
No
Do you give DREAM Alive Permission to view your student's classroom grades and attendance?
*
Yes
No
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Emergency Contact Info
Food or Airborne Allergies
*
Any medical conditions that we should be aware of?
*
Hospital Preference
*
Physician's Name
*
Emergency Contact
*
Guardian #1
Guardian #2
Emergency Contact (if other than Guardian)
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Emergency Contact Email
*
DO NOT USE THE SAME EMAIL FOR BOTH GUARDIAN AND STUDENT. If you don't have an email, please type out [yourfirstname]@[yourlastname].com. Thank you
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--- RELEASE, WAIVER OF LIABILITY AND INDENIFICATION--
General
By signing electronically, I hereby agree to release and hold harmless D.R.E.A.M. Alive, Incorporated, its affiliates, subsidiaries, employees, officers, directors, employees, and the Indianapolis Colts Organization from and against all liability as a result of my student’s participation in ALL APPROVED D.R.E.A.M. Alive, Incorporated programming and/or events. Moreover, as the parent(s) and/or legal guardian(s) of the above-referenced student, I agree to indemnify and hold D.R.E.A.M. Alive, Inc. and it’s agents, employees, individual staff and volunteer harmless against any and all claims, liabilities, losses, damages, or expenses of any kind, including reasonable attorney fees, sustained as a result of participation in any and all after-school programming and/or events held by D.R.E.A.M. Alive, Incorporated.
Scholar Programming and Trips
I give my child permission to participate in D.R.E.A.M. Alive, Inc. Programming and attend field Enrichment trips sponsored and/or hosted by D.R.E.A.M. Alive, Inc. to local establishments, businesses, colleges, universities and attractions throughout Indiana and surrounding states. I give my child permission for D.R.E.A.M Alive, Inc Staff to have in school visitation to participate in lunch mentoring and visitation. I hereby grant permission of my son/daughter to be transported by D.R.E.A.M. Alive, Inc. staff and other program instructors in conjunction with attendance and activities directly related to his/her participation in ALL D.R.E.A.M. Alive, Inc. programming held at approved after-school programming sites and venues. Programming includes, but not exclusive to, ALL D.R.E.A.M. partnerships, sponsorships, and collaborations, whether taking place daily, weekly, monthly, annually or otherwise. I understand every reasonable precaution will be taken to safeguard my child at all times. Furthermore, I understand adequate and appropriate supervision will be provided at all times during programming.I have read the above provisions and I do hereby give my permission for my child to fully participate in all in school and after-school Programming, D.R.E.A.M Alive, Inc Staff lunch visitation, lunch mentoring, attend field trips and/or outside events/activities sponsored by D.R.E.A.M. Alive, Incorporated and be transported by D.R.E.A.M. Alive, Incorporated and/or its designated agents or contractors. I understand that the student, my child participates in D.R.E.A.M. Alive, Incorporated programming, events, trips, and activities at his/her own risk.
Guardian Electronic Signature for Release and Waiver of LIability
By typing your name here (the guardian), you are entering into a legally binding agreement with DREAM Alive, agreeing to the release, waiver of liability and indemnification as specifically written above.
Sign below
*
Media Release
I grant to D.R.E.A.M. Alive, Inc. the exclusive right to use my child's interview/photograph/video or film likeness in media and promotional materials. I authorized others to use all or any part of my child’s interview, photograph, video in related media such as books, magazines, journals, pamphlets, electronic (internet) and other written and video formats. The undersigned also releases D.R.E.A.M. Alive, Inc and its directors, its members, trustees, founders, officers, employees, partners, and agents, as well as the Indianapolis Colts and its agents, from any and all claims, demands, causes of action and suits, including by not limited to, claims for invasion of privacy, defamation, breach of contract or other breach of duty arising out of or in connection with the use of any interview, photograph, video or other media representations.
Sign Below
*
Submit
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