Thumbs Up Teen Participant Waiver
Youth Information
Name
*
First Name
Last Name
Nickname
Date of Birth
*
-
Month
-
Day
Year
Date
Grade
*
Please Select
5th
6th
7th
8th
9th
10th
11th
12th
Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth Cell Phone #
Please enter a valid phone number.
Youth Email
example@example.com
Parent/Guardian Information
Parent First & Last Name
*
First Name
Last Name
Parent First & Last Name (optional)
First Name
Last Name
Parental Email
*
example@example.com
List all phone numbers where the parent/guardian can be reached (type: i.e. home, cell)
*
Please enter a valid phone number.
Phone Number (optional)
Please enter a valid phone number.
Phone Number (optional)
Please enter a valid phone number.
Primary Care Physician
First Name
Last Name
Primary Care Physician
Primary Care Physician Phone
Please enter a valid phone number.
Name of Clinic
Any food allergies or restrictions? If yes, list below.
Parental Consent
The undersigned does herby give permission for my child (child's name/participant):
*
to attend and participate in any Thumbs Up activities and events. LIABILITY RELEASE: In consideration of Thumbs Up allowing the Participant to participate in all activities at, and in community location, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Thumbs Up High 5K, Inc, it's directors, employees and volunteers. (collectively herein the “staff”) from any an all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant while involved in the activities. I the parent or legal guardian of this Participant hereby grant my permission for the participant to participate fully in activities at Thumbs Up including trips away from the premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness or death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify Thumbs Up High 5K, Inc. for any liability sustained by said “Staff” as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the Medical Practice Act on the medical staff or a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.
*
Parent First Name
Parent Last Name
Parent Signature
*
Youth Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Thumbs Up Photo Release Form for Participants and Volunteers
I agree that Thumbs Up may photograph and record my child/dependent’s likeness and activities (Images)* during Thumbs Up activities. I grant the following rights to Thumbs Up: permission to use and re-use, publish and re-publish. Use of the images for editorial commercial, advertising, and any other purpose may be done in any medi um now existing or subsequently developed, on the Thumbs Up website and on the Internet, and worldwide perpetuity for the purposes stated above. Names of those photographed will not be published. I waive my right to inspect or approve any editorial text or copy that is used in connec tion with the Image and relate and discharge Thumbs Up from any and all claims aris ing out of the use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortious act. I have read the foregoing. I fully understand its contents, I understand that this agree ment does not expire and I confirm my agreement by signing below. I am over the age of 18 and hav legal capacity to sign the release.
Youth Name Printed
First Name
Last Name
Parent/Guardian Name Printed
First Name
Last Name
Parent/Guardian Signiture
Today's Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Email Address
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Thumbs Up Covenant of Community Expectations
The following rules and guidelines are equally binding on volunteers and youth. Non-Negotiable Rules 1. No use of illicit drugs or alcohol. 2. No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally cover by undergarments). 1. Including no sexual promiscuity/PDA 3. Smoking, vaping, and the use of tobacco products are not allowed on the premises or to, from, or during any trip. 4. Participants will not break any American laws in the United States or any other country. 5. Participants will adhere to all internet rules and restrictions that have been set up by Thumbs Up. 6. Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times. 7. Participants will be respectful of both our space and property as well as the property of others. 8. Participants will avoid the use of foul language, cursing, or any speech (including “humor”) which puts down, makes fun of, or stereotypes other persons or groups. Participant/Volunteer’s Statement: By signing this form, I pledge to honor and respect others during this activity by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file.
Youth Participant or Volunteer’s Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Parent/Guardian’s Statement: By signing this form, I agree to support the Covenant of Community Expectations printed above.
*
Today's Date
*
-
Month
-
Day
Year
Date
Thumbs Up Internet Acceptable Use Policy
The following rules are not permitted: • Sending or displaying offensive messages or pictures • Harassing, insulting or attacking others • Violating copyright laws • Employing the network for commercial purposes • Using another’s ID password • Intentionally wasting limited resources (paper, ink, etc.) • Do not share your personal information on the internet I understand and will abide by this Acceptable Use Policy. I further understand that any violation of the regulations above may cause my access to privileges to be revoked and may result in appropriate legal action against me.
Users Full Name
*
First Name
Last Name
User's Full Signature:
*
Today's Date
*
-
Month
-
Day
Year
Date
Supervision
Thumbs Up activities and events are staffed by adult volunteers and staff members who have successfully passed a background check, and have agreed to Thumbs up rules, regulations, and values. Thumbs Up aims to have a minimum of two volunteers per activity/event. Thumbs Up is unable to provide one-on-one direct supervision to participants. If a participant is in need of any level of increased supervision due to physical, emotional, and/or behavioral limitations/ concerns, the undersigned should contact Thumbs Up directly to discuss if any accommodation can be arranged. If the participant has any legal restrictions regarding contact with any individual or group of individuals, the undersigned must contact Thumbs Up directly to discuss if any accommodation can be arranged. There will be a therapy dog on site from time to time as we partner with You Are Not Alone. If you have any issues or concerns with there being a therapy dog at Thumbs Up, please let our staff know.
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