Consent, Release of Liability, and Photo Release Form

Unlock the Power of Decision Making

A Revolutionary Class for Teens | Class Date: March 16, 2024
Student Agreement and Release Form

Please fill out the following student release form for each participant your are registering for the class. Follow the link provided after submission to fill out additional release forms.
Primary Parent | Guardian’s Name:
Full Name
Primary Parent | Guardian’s Email:
example@example.com
Primary Parent | Guardian Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Participant
Class Participant Information
Participant's Name

First NameLast Name
Pronouns
Age
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Conditions and Special Requirements
Please detail any medical conditions, allergies, dietary restrictions, or special accommodations required:
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Should this person be contacted first in an emergency situation?
Emergency Contact Email:
example@example.com
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Participant
Consent and Release of Liability Agreement

I, the undersigned (or parent/legal guardian of the participant named above, if under 18 years of age), acknowledge the inherent risks associated with participation in Clarity4Action’s Teen Decision Making Course, including but not limited to physical injury and mental stress. By signing this form, I release Clarity4Action, including its directors, employees, and volunteers, from any liability for injury, loss, or damage arising from participation in the course, whether due to negligence or any other cause.

I confirm that the participant is in good health and physically capable of taking part in all course activities, and I have disclosed any medical or health-related conditions that the course leaders should be aware of in the space provided below.
Parent | Guardian Name
Relationship to Participant
Photo and Media Release Consent

I hereby grant permission to Clarity4Action to take and use: photographs, video recordings, and/or audio recordings of the participant, including for use in promotional materials and publications. The student’s name will not be shared publicly. I authorize the use of these materials indefinitely without compensation to me or the participant.
Parent | Guardian's Name
Relationship to Participant
Acknowledgement and Signature

By signing below, I affirm that I have read, fully understand, and agree to the terms of this Consent, Release of Liability, and Photo Release Form. I understand that this is a release of liability and a contract and sign it of my own free will.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent | Guardian’s Signature:
Should be Empty:

Unlock the Power of Decision Making

Student Agreement and Release Form

Class Participant Information

Medical Conditions and Special Requirements

Emergency Contact Information

Consent and Release of Liability Agreement

Photo and Media Release Consent

Acknowledgement and Signature