Terms of Agreement
PART 1: AGREEMENT TO PARTICIPATE AND HOLD HARMLESS
I, the parent or legal guardian of the child listed above, hereby grant permission for my child to participate in the Urban City Impact Mentorship Program.
I understand that participation in the program involves certain inherent risks and dangers, including but not limited to: loss of personal property, physical injury, or fatality resulting from activities such as sports, exercise, use of workout equipment, cooking, chopping firewood, tripping or falling, exposure to heights or water (including risk of drowning), allergic reactions (to food, plants, animals, or insects), animal bites, extreme temperatures or inclement weather, and vehicle accidents.
My child and I agree to follow all safety procedures, program rules, and instructions provided by Urban City Impact staff. We acknowledge that Urban City Impact, its employees, volunteers, and other participants are not liable for any injuries, illnesses, losses, or damages arising from participation in program activities. We voluntarily assume all risks associated with the program and agree to release and hold harmless Urban City Impact and its representatives from any and all claims, liabilities, or damages resulting from our participation.
PART 2: AGREEMENT TO FOLLOW RULES
I understand that my child's participation in the mentorship program is conditional upon their maintaining good health and behavior. I agree to ensure that my child does not attend program activities while ill and that they are ready for pick-up at least 15 minutes prior to scheduled pick-up times.
I understand that the possession, use, or distribution of weapons or prohibited substances—including, but not limited to, vapes and illicit drugs—is strictly prohibited. Any violation of this policy may result in immediate suspension or permanent removal from the program. I confirm that I have reviewed Urban City Impact’s Student Handbook with my child, and both my child and I agree to fully comply with all program rules and expectations, whether communicated in writing or verbally by staff.
PART 3: PHOTO AND MEDIA RELEASE
I hereby authorize Urban City Impact, its staff, and volunteers to use photographs, video recordings, audio recordings, and other media that include my child for promotional, educational, or other legitimate purposes related to Urban City Impact’s mission and activities.
PART 4: SAFETY AND CRISIS INTERVENTION CONSENT
I understand and agree that, in the event my child poses an immediate physical threat to themselves or others during participation in Urban City Impact programs, if verbal de-escalation techniques are unsuccessful, trained staff may employ physical restraint as a last resort to prevent imminent harm.
I acknowledge that any use of restraint will be conducted in accordance with applicable laws, safety protocols, and best practices, and only by staff who have received appropriate training. I further understand that restraint will be used solely for the purpose of ensuring safety and will be discontinued as soon as the risk has been mitigated.
PART 5: SEARCH AND POSESSION CHECK CONSENT
In order to maintain a safe and secure environment for all participants, I acknowledge and agree that my child may be subject to possession checks, including pat-down searches, in the event of a reported theft, suspicion of contraband, or concern regarding the presence of a weapon.
I understand that pat-down searches will be conducted only when deemed necessary by Urban City Impact staff member of the same sex as the student being searched and will take place in the presence of a witness. Searches will be conducted respectfully and in accordance with applicable legal and organizational standards, with the intent of protecting the safety of all students, staff, and volunteers.
PART 6: MEDICAL INFORMATION DISCLOSURE AGREEMENT
I acknowledge and agree that it is my ongoing responsibility to provide Urban City Impact with immediate written notice of any newly diagnosed medical conditions, allergies, or changes in my child’s physical or mental health that could affect their ability to safely participate in program activities.
PART 7: 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 any activities or trips.
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.