If you are under 18 years of age, your legal guardian/parent must review and complete the remainder of the form with you.

In consideration of the permission granted by me and to the Student for the Student’s participation in the Youth Ambassador Program, we, the Student and the Parent or Guardian, to the extent permitted by law, do hereby:

1. assume any and all risk and liability for losses or damages to property and for damages, injuries or death which may arise in connection with travel to or participation in activities, programs related to the Youth Ambassador Program, and hereby, for the Student and for myself and our heirs, executors, administrators, successors and assigns, do release and discharge the New Jersey Department of Law & Public Safety its divisions, agencies, offices, as well as its employees, officers, and agents (collectively “Department”), from any and all claims, actions, and liabilities arising from or relating to travel to or participation in activities, programs or functions sponsored by the Department; and
2. grant permission for video graphic, photographic or audio recording of the Student’s participation in activities, programs or functions sponsored by the Department, and for the use of such videos, photographs, and recordings by or with the consent of the Department for promotional and educational purposes; and
3. permit the Department to survey the Student about the program’s impact and to publicly release aggregated survey results,and authorize and permit the Department to provide copies of this Consent Form to others as the Department deems necessary or appropriate; and
4. acknowledge that the Student is not guaranteed an opportunity to participate in the Youth Ambassador Program and that no commitment is being made that the Student will have such an opportunity, and agree that the Department may, at its sole discretion, suspend, dismiss or discontinue the Student's participation in the program at any time, including circumstances in which the Student’s team or affiliate leaders believe that the Student’s behavior or engagement does not meet expectations, is disruptive or is less than appropriate for the Student or other students to benefit from the program; and
5. consent and agree that should the Department believe that the Student may be a danger to themselves or others, or a victim of abuse, bullying, neglect or other such difficulties, the Department may report this concern and the circumstances giving rise to the concern to the Student's school, guidance counselor or other authorities, as the Department may determine appropriate in its discretion, whether or not required to do so by law; and
6. will not represent myself in any forum, including through online activities and social media as a representative of the Department for any purpose whatsoever, and in making any public statements will advise that any statements made are my personal opinions and do not necessarily represent the views of the State of New Jersey, the Department or the Division on Civil Rights.

We have carefully read the foregoing consent and release and know and understand the contents thereof. We sign this consent and release voluntarily as our own free act with knowledge of its significance, and intend to be legally bound thereby.

If you are under 18 years of age, your legal guardian/parent provide their signature.