GLSEN NM - Youth Participant and Parent(s)/Guardian(s) Agreement

Event Name: TQA Pride Summit
Event Date: April 22, 2023
Event Time: 9:00 AM - 3:30 PM

Event Information: The TQA Pride Summit is a day-long institute that provides workshops and other educational opportunities for attendees to network and learn in a shared environement.

Youth Participant's Name*

First NameLast Name

Age*

Date of Birth*

Date

Youth Participant's Phone Number

Youth Participant's Email

Parent/Legal Guardian Name*

First NameLast Name

Relationship to the Minor*

Phone Number 1*

Phone Number 2

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Emergency Contact Email

example@example.com

Does the Youth Participant have any allergies?

YesNo

Medications taken regularly:

Physical accommodations:

Does the Youth Participant have any medical conditions that you would like to declare?

Any special instructions?

Medical Release

This certifies that the participant is physically able to participate in activities with the exception of those noted, and that immediate medical attention may be obtained if necessary. Approval is also given for the participant to participate in activities sanctioned by GLSEN, Inc. By signing below parent(s)/legal guardian(s) hereby agree to indemnify and hold harmless and forever release GLSEN, Inc. and its directors, officers, employees and agents against and from any and all claims and damages, suits and proceedings, medical expense or expense of every type, all or part thereof which arise out of or relate to any activities of the participant or GLSEN, including but not limited to acts or omissions of GLSEN.

In the event of an emergency, GLSEN representatives are authorized to engage a licensed doctor to render medical services which may, in the sole discretion of the doctor, be necessary; GLSEN representatives are also authorized to take participants to the hospital if necessary and parent(s)/legal guardian(s) agree to pay all doctor, hospital and related bills.

GLSEN General Rules of Conduct
While attending the workshop, participants agree to abide by the following rules:

Participants are asked to be respectful of all other participants and staff;
Participants are asked to fully participate in the event, including arriving on time;
Participants are prohibited from using or possessing any drugs or alcohol;
Participants agree not to engage in any illegal activity whatsoever;
Participants agree not to engage in any sexualized behavior (including inappropriate touching or comments);
Participants will help ensure the safety of all participants by immediately alerting staff to any health or safety issues or any activities that violate the general rules or otherwise compromise the safety or well-being of other participants;
GLSEN reserves the right to a range of consequences for any participant who breaks one of these rules or whose behavior is disruptive to the event and/or other participants, which includes contacting parent(s)/legal guardian(s) and/or removal from the event.

Youth Participant(s)/Legal Guardian(s) Agreement: GLSEN envisions a future in which every child learns to respect and accept all people, regardless of sexual orientation or gender identity/expression. We want all participants to have an empowering experience and to make sure that the environment will be comfortable and safe for everyone. Therefore, it is understood and agreed by the participant and parent(s)/legal guardian(s) that all participants will abide by the GLSEN General Rules of Conduct. Violation of this agreement is unacceptable and participants may be sent home (at the cost of the participant and parent(s)/legal guardian(s)) and forfeit all future opportunities to attend GLSEN events, participate in leadership programs and/or receive GLSEN scholarships. Participant’s and legal guardian’s signatures constitute understanding and agreement of the above rules.

I, {youthParticipants}, agree follow all the event guidelines stated in this form.

Youth Participant Signature *

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Date Signed (Youth Participant)*

Date

I, {parentlegalGuardian}, the parent or legal guardian of Youth Partipant, give my permission to join or participate in the Event stated in this form.

Parent/ Guardian Signature*

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Date Signed (Parent/ Guardian) *

Date