Rogers Smile Club Sign Up & Participant Waiver

Student Full Name

First NameMiddle NameLast Name

Preferred Pronouns and/or Nickname

Grade Level

for Incoming A.Y. '12-'13

School Attending

Date of Birth

Date

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The Rogers Smile Club is open Tuesday-Thursday, 2:15-5:00 PM. Please select the day(s) that will be attended most consistently.

Please select the planned method of transportation for the student to and from the program.

If other, please explain.

I understand and agree that my student will be picked up no later than 5:00 PM from the Smile Club. If an unforeseen event delays this timeline, I will contact Thumbs Up Staff.

Parent or Legal Guardian Name

First NameLast Name

Parent or Legal Guardian Email

example@example.com

Parent or Legal Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Parent or Legal Guardian Name (optional)

First NameLast Name

Secondary Parent or Legal Guardian Email (optional)

example@example.com

Secondary Phone Number (optional)

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact

First NameLast Name

Relationship

ex. Father, Mother, etc.

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Medical Clinic

Primary Care Physician

First NameLast Name

Primary Care Physician Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Does the student have any food allergies or restrictions? If yes, please list below.

Does the student require special accommodations related to mental health, sensory or safety concerns, etc? If yes, please explain.

Community Expectations

The following rules and guidelines are equally binding on volunteers and students. 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), 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.

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.) • Sharing your personal information on the internet. Student understands and will abide by this Acceptable Use Policy. Student further understands that any violation of the regulations above may cause access to privileges to be revoked and may result in appropriate legal action.

Photo Release

I agree that Thumbs Up may photograph and record my student's likeness and activities 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 medium 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 connection with the Images and relate and discharge Thumbs Up from any and all claims arising 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 agreement does not expire and I confirm my agreement by signing below. I am over the age of 18 and have legal capacity to sign the release.

Supervision & Liability Release

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. Therapy dogs will be on site on an occasional basis through You're Not Alone;, a partner organization of Thumbs Up. If there are any issues or concerns with a therapy dog on site at Thumbs Up, the undersigned must contact Thumbs Up staff.

The undersigned does herby give permission for student (student's name) :

to attend and participate in any Thumbs Up activity or event. LIABILITY RELEASE: In consideration of Thumbs Up allowing the student 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 student hereby grant my permission for the student to participate fully in activities at Thumbs Up including trips away from the premises. Furthermore, I, on behalf of my minor student, 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 student, including expenses incurred attendant thereto. MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the student 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 student pursuant to this authorization.

Parent or Legal Guardian Signature

Rogers Smile Club Sign Up & Participant Waiver

Student Information

Parent/Legal Guardian Information

Emergency & Medical Information

Consent & Release of Liability