Permission Form

Mentorship Permission Form

We must receive a completed permission form for your child prior to their participation in our mentorship outings. This permission form will cover the majority of our upcoming activities.

Student Information

Student's Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What school does your child attend?*

Parent/Guardian Info

Parent/Guardian Name*

First NameLast Name

Relationship*

Primary Phone Number*

Secondary Phone Number

E-mail*

Emergency Contact & Health Insurance Information

Primary Emergency Contact*

First NameLast Name

Relationship*

Phone Number*

Secondary Emergency Contact*

First NameLast Name

Relationship*

Phone Number*

Does your child have any allergies?*

YesNo

Please provide a description:*

Is your child covered with health insurance?*

YesNo, I'll cover medical expenses with cash.

Insurance Carrier*

Name of Policy Holder*

Subscriber ID/Group Number*

Insurance Card Number/Date*

Name of Primary Care Physician

Name of Clinic

Clinic Phone Number

Important Information

· Please do not allow your child to attend if they are sick.

· If your child cannot attend for any reason, please let us know as soon as possible so we can give another student the opportunity to participate in their absence.

· Please ensure that your child is ready for pick-up 15 minutes prior to their scheduled pick up times. Pick up and drop off times may fluctuate based on traffic.

· In the event that an Urban City Impact staff member falls ill or has an emergency, outings might be cancelled or rescheduled for a later date.

· We have the same rules and expectations as your child's school.

· Use of illegal substances will not be tolerated. If your child uses vapes or other products that are forbidden to them by law, please urge them to leave the products at home. If such products are seen, they will be confiscated. If confiscation leads to altercation, your child will be suspended from all Urban City Impact activities and events for a period of time.

· Major behavior infractions are cause for suspension from future mentorship programs and outings for a period of time.

Terms of Agreement

PART 1: AGREEMENT TO PARTICIPATE AND HOLD HARMLESS

I am the parent or guardian of the child listed above and I authorize my child, for his/her own benefit, to participate in Urban City Impact's mentorship program.

In agreement to participate in mentorship program, my child and I recognize that certain risks and dangers exist. These risks include but are not limited to the loss of personal property, personal injury or fatality, which may result from participating in sports, using workout equipment, exercising, cooking, chopping firewood, tripping, falling from heights, drowning, allergic reactions to food or insects, exposure to extreme temperature or inclimate weather, and vehicle accidents.

My child and I agree to obey the rules and safety procedures for the mentorship program. We also agree to obey the instructions of the staff directing the events and understand that Urban City Impact, its staff, and other participants shall assume no responsibility or liability to me for accidents, illness, personal injury, or loss or damage to personal property caused by risks inherent in the activities in which my child and I are willing participants. I acknowledge and assume all risks in connection with this mentorship program, and I hold Urban City Impact and its agents harmless from any and all liability, action, claims, and damage of every kind.

PART 2: PHOTO RELEASE

Furthermore, I hereby grant permission to Urban City Impact, its staff and volunteers to use any photographs, motion pictures, recordings, and any other record of my child's participation in Urban City Impact's activities and events for any legitimate purpose.

PART 3: AUTHORIZATION FOR EMERGENCY MEDICAL CARE

I am aware of my child’s general condition and affirm that he/she is fit to participate in any activities required for participation in Urban City Impact's outings. I willfully disclose any relevant medical information on this form and to Urban City Impact's staff. My child will engage in all prescribed activities except for those noted by me and/or by my examining physician. I agree to provide medical documentation and I permit the staff to contact my child’s healthcare providers to inquire of medical needs and I authorize the staff to copy and release my child’s medical information to those who need to review it for purposes related to Urban City Impact's events and activities. If required by the Health Insurance and Accountability Act (“HIPAA”) to execute medical releases, I will execute all such releases pursuant to HIPAA, prior to my child engaging in the activity or trip.

In the event of illness, accident or emergency, I authorize and request that any medical and surgical services that may be necessary be taken, and further agree to accept financial responsibility to seek approval from a medical provider in order for my child to participate in Urban City Impact's mentorship program and its activities should his/her physical, mental or medical status change.

By my signature, I acknowledge that I have read and understand this form in its entirety. I also acknowledge that I agree to the terms listed above. Furthermore, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge*