I consent to have my child photographed or videotaped while participating in Nurture House Group functions. I consent to the use of my child's photogaph or likeness on the Nurture House Group social media platforms, website, and/or other media associated with Nurture House Group.

As the child's parent or legal guardian, I agree that no compensation or other considerations will become due to me or my child because of my child's participation in these activities.

I give written permission to Nurture House Group to send, receive and provide verbal information to participating partners regarding. The participant’s name, date of birth, contact information, parent/guardian information, and any healthcare information will be provided if law-enforcement or medical care is needed. Parents will be contacted immediately in case of any emergencies. An expiration date or expiration event is one year from the date signed.

I hereby give my approval for my child’s participation in any and all activities prepared by Nurture House Group. In exchange for the acceptance of said child’s candidacy by Nurture House Group. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Nurture House Group, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from the Nurture House Group program.

In case of injury to said child, I hereby waive all claims against Nurture House Group, including all volunteers, all participants, sponsoring agencies, staff, and, if applicable, owners and lessors of premises used to conduct the event.

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Nurture House Group and its affiliates including Directors and volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

By signing this Consent to Access Information form, you allow your child’s school as well as Nurture House Group, your child's tutoring organization, to release documents to each other containing educational records pertaining to your child. The following records may be disclosed:

1. Your child’s Individualized Education Program (IEP/504), Individual Health Plan (IHP), and/or Individualized Family Service Plan (IFSP);

2. Medical and behavioral health records, including information that is contained in your child’s educational records; and

3. Educational reports, grades, records, or relevant special education evaluation results contained in your child’s educational records.

The purpose of this form is to allow access to information that will allow the organization providing tutoring services, Nurture House Group, the ability to better serve your child’s needs by being able to communicate with school staff about your child and the services listed above.

By signing this form, you are giving consent for the above listed records to be released to Nurture House Group and the child’s school.

Nurture House Group is a youth-serving organization dedicated to the advancement and enrichment of at-risk youth by encouraging purposeful living and offering a structured environment. The activities outlined below are prohibited. Any participant who violates this code may be suspended or removed from the program.

• Abusive language towards a staff member, volunteer, or another participant. Possession or use of alcoholic beverages or illegal drugs on the property or reporting to the program while under the influence of drugs or alcohol.

• Bringing dangerous or unauthorized materials (firearms, weapons, or other similar items) onto the property.

• Discourtesy or rudeness to a fellow participant, staff member, or volunteer.

• Verbal, physical, or visual harassment of another participant, staff member, or volunteer.

• Threatening,bullying, or violence towards any individual.

• Failing to cooperate with an adult supervisor, leader, or mentor.

• Taking any materials that belong to the program without permission from a staff member.

• Intentionally damaging program property or facility.

• Leaving the facility without being signed out.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.