She Speaks Power!

EMERGENCY CONTACT
Name of Emergency Contact:*

First NameLast Name
Relation to Student:*
Phone Number for Emergency Contact:*
Please enter a valid phone number.

LEGAL PARENT/GAURDIAN INFORMATION
Legal Parent/Guardian's Name:*

First NameLast Name
Legal Parent/Guardian's Phone Number:*
Please enter a valid phone number.
Do you wish to receive text messages about the program for the phone number provided:*
Message and data rates may apply. Participants can opt-out of messages by texting "STOP" to (609) 522-5960.
Legal Parent/Guardian's Email:*

Confirmation Emailexample@example.com
Legal Parent/Guardian's Address:*

Street Address

Street Address Line 2

CityState

Zip Code

LEGAL PARENT/GUARDIAN CONSENT FORM
Consent to Participate

I, {legalParentguardians23}, being the parent/legal guardian of {studentsName}, do hereby give my consent for my child to participate in the She Speaks Power! Program facilitated by Cape Assist. I acknowledge that this program may involve physical activities that could include risks such as injuries.

Release and Waiver of Liability

I understand that participation in this program carries with it the potential for certain risks, some of which may not be reasonably foreseeable. I hereby release, waive, discharge, and covenant not to sue Cape Assist, its affiliates, their directors, officers, employees, volunteers, representatives, and agents from any and all liabilities, claims, demands, or injuries, including death, that may be sustained by my child while participating in this program, including travel to and from this program.

Photo and Media Release

I hereby grant Cape Assist and its affiliates the right to use my child's name, photograph, age, grade, school, likeness, voice, video, and artwork for promotional, advertising, and educational purposes in various formats, including print, digital, and online. These rights extend indefinitely unless I choose to withdraw consent.

To withdraw my consent, I understand that I must do so in writing and send my request via certified mail to:

Cape Assist
3819 New Jersey Avenue
Wildwood, NJ 08260

I acknowledge that Cape Assist has up to 60 days from the date they receive my written notice to process my withdrawal.
Legal Parent/Guardian Signature:

Clear
Today's Date:*

MonthDayYear
Date
Should be Empty:

She Speaks Power!

STUDENT INFORMATION

EMERGENCY CONTACT

LEGAL PARENT/GAURDIAN INFORMATION

LEGAL PARENT/GUARDIAN CONSENT FORM