Dear Parent and/or Legal Guardian,
Please read this Parental Consent form and the accompanying Release of Identifiable Information & Media Release forms carefully. If you wish to give consent, please complete and digitally sign this Parental Consent form. PEERS Student Applications that do not have a properly signed and completed Parental Consent form will not be accepted by The PEERS Project. Students who are 18 years of age or older may complete and sign the Parental Consent form themselves.
I hereby give my son/daughter, (listed within this form)(hereinafter referred to as "my student'·), permission to participate in The PEERS Project mentor program.
By digitally signing this form, I am giving The PEERS Project staff permission to communicate with the staff and administrators of my student's school regarding services offered to my student by either entity. In addition, by signing this form, I am authorizing the exchange of documents and information between The PEERS Project and my student's school, which is specifically defined below. I understand that all records and information regarding services is protected by the Family Educational Rights Privacy Act, which governs the exchange of confidential information.
The PEERS Project would like to publicize activities and events taking place in the program. As such, The PEERS Project seeks permission to use the following information, some of which may be considered personally identifiable information as defined and contemplated by the Family Education Rights and Privacy Act. The information The PEERS Project seeks to use includes: first and last name, school name, location, voice, photograph, image, and/or likeness. This information, including the right and license to use any comments, quotes or statements, may be published in electronic or other print media format including, but not limited to, The PEERS Project website, The PEERS Project Facebook page, The PEERS Project lnstagram account and The PEERS Project You Tube channel. It is important to understand that posting licensed material and identifiable information online presents potential risks, as The PEERS Project cannot control who may access such information.
I GRANT The PEERS Project permission to use my student's name, licensed material and identifiable information (as defined and limited herein), without payment or any other consideration.
I understand and agree these materials will be collected by The PEERS Project. I hereby authorize The PEERS Project to edit, alter, copy. exhibit. publish, and/or distribute my student's licensed material and identifiable information. I waive the right to inspect or approve licensed material and identifiable information to which this release applies.
I hereby give permission for The PEERS Project to obtain information on:
• PEERS Student Application(s)
• Student Directory lnformation, which shall specifically include demographic data and contact information
• Family Demographics
• Academic Performance
• Disciplinary Issues
At no time and under no circumstances, will The PEERS Project release, sell, or otherwise distribute information unless authorized to do so in writing or as required by law. this authorization to receive services from The PEERS Project and to exchange confidential and personally identifiable information shall remain in effect for one calendar year from the date this authorization is signed by the parent/legal guardian or eligible student.
By signing this release, I am granting my student permission to drive with The PEERS Project staff or another PEERS Mentor to any PEERS Project presentation or activity. In acknowledgement of the risk of injury while participating in activities for The PEERS Project and in consideration for the right to participate in the PEERS Project, I hereby, for myself and my student knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my or my student's participation in The PEERS Project and do hereby waive release and forever discharge The PEERS Project and its affiliates, and their respective managers, members, directors, attorneys, staff, employees, volunteers, and representatives, from any known or unknown, foreseeable or unforeseeable, anticipated or unanticipated, claims, actions, demands, damages, losses, costs, liabilities and/or expenses (including without limitation attorney and expert fees), whether such arises based on negligence or by any statutory or common law theories (collectively "Claims"), including but not limited to any Claims related to any personal, physical, psychological, economical or emotional injury, illness, paralysis or death, arising out of or in connection with or related to my student's participation in The PEERS Project, including traveling to and from an event related to The PEERS Project.
I agree to indemnify and hold harmless The PEERS Project and its affiliates, and their respective managers, members, directors, attorneys, staff, employees, volunteers, and representatives from and against any and all Claims arising out of or in connection with, directly or indirectly growing out of, related to, or caused in whole ore in part by my student's participation in The PEERS Project even though that liability may arise out of the partial negligence or carelessness on the part of such released parties. I understand and agree that this agreement applies whether The PEERS Project is at fault or not, to the fullest extent permitted by law. In the event of litigation to enforce or otherwise concerning any provision of this instrument. The PEERS Project and its related entities shall be entitled to recover their costs, expenses, and reasonable attorney fees incurred in such litigation. This waiver, release and indemnity shall be binding on all respective heirs, devices, personal representatives, successors and assigns of all parties to this agreement.
The undersigned acknowledge and agree that they have read and understand this document prior to signing below and understand that this document contains a promise not to sue The PEERS Project and related parties and a release and indemnity for all Claims.