ANYTOWN PARTICIPANT APPLICATION

I, parent/or guardian of blanks(parent's name) expressly authorize any Community Tampa Bay representative to administer to the applicant the medications I have listed in the Community Tampa Bay ANYTOWN application that was submitted by the applicant or checked on the list above. All medication prescribed or over the counter must be given to volunteer staff upon arrival.

I further authorize and grant permission for any Community Tampa Bay representative to contact the prescribing physician(s)for such medication(s) in order to exchange information concerning the medications listed in the Community Tampa Bay ANYTOWN application.

The Information provided on this form is correct and complete to the best of my knowledge and I authorize the release of the medical information on this form as is pertinent to my child's condition. Moreover, the applicant has permission to engage in program activities except as noted on this "Health History and Medical Release Form"

In consideration for Community Tampa Bay's arranging this opportunity to participate in ANYTOWN and having read and understood this consent and release form. I (parent/guardian) blank here by agree to the following:



I understand that ANYTOWN® is a youth leadership and diversity education program that deals with sensitive subject matters. Discussion topics may include values clarification, self-reflection, stereotypes and prejudice, interpersonal communication, identity, racism, sexism, homophobia, classism, genocide, power and privilege, and other issues of social justice. My/my child’s participation in ANYTOWN® is entirely voluntary and I am/my child is under no obligation to take part in the program. I realize that the ANYTOWN® program is exclusively under the auspices of Community Tampa Bay and is their sole responsibility although the program is located on Eckerd College premises.
 
I understand that Participants may find ANYTOWN® to be an emotional experience. Throughout the program, Participants may experience confusion, anger, joy, sadness, frustration, hope and other emotions as they learn about the impact discrimination has on the lives of individuals. I affirm that I/my child has no known mental or emotional conditions or sensitivities that would interfere with participation and that I/my child is capable of handling the subject matter and emotional nature of this program.
 
I agree to inform Community Tampa Bay of any changes in my/my child’s medical information as stated in the Health History and Medical Release Form. I understand that in an emergency situation, there is a possibility that I/my child may be transported by Community Tampa Bay employees, volunteers or representatives if the situation should warrant it. I also understand that, although Community Tampa Bay has used great care to provide organization, supervision, instruction, and equipment for each activity, it is impossible for Community Tampa Bay to guarantee Participants’ absolute safety. I acknowledge that each Participant shares the responsibility for making an activity a safe experience for all Participants through appropriate behavior and conduct. I/my child agree(s) to follow directions of the activity leaders at ANYTOWN® and not deviate from the planned activities. I understand that Community Tampa Bay reserves the right to dismiss me/my child from ANYTOWN® for any reason, including but not limited to verbal and physical aggression against any ANYTOWN® representative or other Participant, failure to follow safety or program instructions, or for any other disruptive behavior, if, in Community Tampa Bay’s sole discretion, my/my child’s continued participation would threaten the success of the program. If the Executive Director or Program Director must send my child home for any reason, I agree to pick up my child within four (4) hours of the Director's call. I understand that I may be called at any time of the night or day to arrange for my child's transportation home and that I will be responsible for all costs associated with such transportation.   
 
I have fully investigated the nature of ANYTOWN® and agree that I/my child will assume the risks of injury or damage that are inherent in any activity and that may occur as part of participation in the program. I understand that no insurance coverage may exist through Community Tampa Bay to cover any claims that may arise out of my/my child’s participation in ANYTOWN®. I agree to bear all financial responsibility for any medical treatment arising from my/my child’s participation in ANYTOWN®.

In consideration of the opportunity to participate in ANYTOWN®, I expressly agree and intend that my/my child’s participation in ANYTOWN® shall be undertaken at my/my child’s own risk and that none of Community Tampa Bay, its officers, directors, employees, lessors, volunteers, agents or assigns shall be liable for any losses, injuries, damages, claims, demands, actions or causes of action whatsoever which may arise out of or in connection with my/my child’s participation in ANYTOWN®, whether from acts of passive or active negligence on my/my child’s part, the part of Community Tampa Bay, its officers, directors, employees, lessors, volunteers, agents or assigns, or the part of third parties. I do hereby forever release, waive, discharge covenant not to sue, and agree to indemnify and hold harmless Community Tampa Bay, its officers, directors, employees, lessors, volunteers, agents and assigns (the “releases”) for any such losses, injuries, damages, claims, demands, actions, or causes of action.
It is my express intent that this consent and release form shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue the above named Releases. I agree that the terms of this consent and release form shall be construed in accordance with the laws of the state of Florida and that the exclusive jurisdiction and venue for any dispute arising between Community Tampa Bay and me involving this consent and release form shall be in the courts located in Pinellas County, Florida. In the event that any term or provision of this consent and release form is found to be unenforceable or void, in whole or in part, such term or provision shall be construed as valid and enforceable to the maximum extent permitted by law, and the balance of this consent and release form shall remain in full force and effect.
I understand that in order to prevent harm, maintain order and ensure the safety and well-being of all Participants and ANYTOWN® representatives, I hereby expressly consent and give permission to Community Tampa Bay and the ANYTOWN® representatives to enter
 
and/or search my child's room or personal belongings when there is reasonable evidence of illegal or dangerous items (including but not limited to, weapons, knives, alcohol, illegal drugs, fireworks or explosives) or stolen property. To the extent possible, the Participant will be present during such a search by an ANYTOWN® representative.