Voices Unbound Enrollment Form

Voices Unbound

Enrollment Form

Collaborating Partners:

OLP GSO, Journey's Counseling Center & Just Me Podcast
Basic Participant Information
Participant Name:
First
M
Last
State
Zip Code
County
Biological Sex
Preferred Pronoun
Date of Birth

MonthDayYear
Date
Age
Participants Email
example@example.com
Guardian Information
Guardian's Name:
First
M
Last
Guardians Best contact number
Guardians Email
example@example.com
Emergency Contact/Medical Information:
Emergency Contact 1
Contact's phone Number
Allergies
HealthConditions
Special Needs Accommodations
I attest that everything listed on this enrollment form is true to the best of my knowledge. I hereby permit a copy of this to be used in place of the original if needed. I (Parent/Guardian), certify that the participant is physically fit for participation in the activities throughout the workshop. I certify that there are no health-related reasons or problems which preclude participation in this 3 day workshop.
ParentGuardians Signature

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Voices Unbound

Consent for Participation

Please read each statement carefully and check the box to indicate your agreement.
All boxes must be checked to complete enrollment.
I ParentGuardian understand that the Participant is expected to follow all workshop rules and instructions provided by organizers and staff Failure to comply may result in dismissal from the workshopI, (Parent/Guardian) understand Voices Unbound requires that participants, parents/guardians be kind and courteous to everyone, and follow instructions issued by facilitators and volunteers. Disruptive behavior that distracts from learning, art-making or the Greensboro Cultural Arts Center's day-to-day operations is not allowed.I, (Parent/Guardian) understand Voices Unbound is committed to maintaining an environment of courtesy, safety, respect and proper conduct among all, including participants, facilitators and volunteers. Failure to adhere to the guidelines, as well as any additional document issued by Voices Unbound, may result in dismissal from workshop and future events.I (Parent/Guardian) understand Voices Unbound does not discriminate on the basis of race, color, national or ethnic origin, ancestry, age, religion or religious creed, disability, sex or gender, gender identity and/or expression, sexual orientation, or any other characteristic protected under applicable federal, state or local law. Nor does it tolerate discriminatory behavior from participants, parents/guardians, facilitators and/or volunteers that might violate such laws.I, (Parent/Guardian) understand Voices Unbound has a Zero-Tolerance Policy against threats or intimidation, stalking, bullying or verbal abuse, gestures of a violent or inappropriate nature, sexual harassment, physical assault, or any other behavior that creates a hostile environment. Any criminal conduct may be reported to the police.I, (Parent/Guardian) understand Voices Unbound is a weapons-free and drug-free program. This includes substances that are illegal to individuals under 18 years of age.I, (the Parent/Guardian) authorize workshop facilitator(s) to seek emergency medical or dental care in the event that participant become ill or have an accident while I am receiving services. I will take full responsibility related to financial coverage for such services if they are needed.I, Parent/Guardian(s) have agreed to refrain from allowing their adolescent to participate in the workshop if participant or additional persons residing in their household demonstrate the following symptoms (Fever, cough, shortness of breath/difficulty breathing, chills, muscle pain, headache, sore throat, loss of taste/smell). Parent/Guardian(s) has agreed to notify facilitators immediately.I, (the Parent/Guardian) have agreed to be responsible for transportation arrangements to/from sessions and will notify facilitators in a timely fashion if unforeseen circumstances arise.I, (the Parent/Guardian) have agreed to be responsible for transportation arrangements to/from sessions and will notify facilitators in a timely fashion if unforeseen circumstances arise.I, (Parent/Guardian) give permission for photographs and videos of participant to be taken during workshops. These images may be used in promotional materials, on social media, and/or on the organization’s (Out Loud Productions, LLC; Just Me Podcast, LLC; Journeys Counseling Center, PLLC) website; without compensation. Participant’s name will not be used in connection with any photos or videos.
**By signing this form, the parent/guardian(s) acknowledges that they have read the summary of the group and is allowing the participant (listed below) to participate in the 3-day workshop for the entire length of program.

Participant's Full Name (Print): Parent/Guardian's Name (Print): Parent/Guardian's Signature:
Participants Full Name Print
ParentGuardians Name Print
ParentGuardians Signature

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Liability Waiver
While there are limited risk associated with participating in this Workshop, there are certain risks associated with participating in workshops that cannot be eliminated. These risks include, but are certainly not limited to: (1) minor injuries such as scratches, cuts, bruises and strains; and (2) major injuries such as injuries to the eyes, infection, loss of sight, joint injuries, back injuries, heart attacks, concussions, paralysis and even death. Also included in these risks are the same or similar injuries that might result from the acts of others or from the unavailability of emergency staff or emergency medical care (hereinafter we shall define all of these risks and potential injuries as "Risks" All these Risks will be present in the activities that you and/or your minor will be participating in with the Voices Unbound 3-day Workshop (the "Activities"

HAVING READ THIS PARAGRAPH and having an appreciation for and an UNDERSTANDING OF THESE RISKS, you hereby affirm that you and the participant's participation in these Activities is voluntary and that you agree on behalf of yourself and the participant to all of the following:

1. ASSUMPTION OF RISK: I, (Parent/Guardian) on behalf of myself and/or my minor, ASSUME ALL

OF THE RISKS THAT MAY OR CAN ARISE OUT OF PARTICIPATING IN THE ACTIVITIES, INCLUDING BUT NOT LIMITED TO THE ACTIVITIES, USE OF EQUIPMENT, FACILITY (Greensboro Cultural Arts Center), THE ACTS OF OTHERS, OR THE UNAVAILABLITY OF EMERGENCY CARE, as well as those Risks described in the preceding paragraph.

2. INDEMNITY/HOLD HARMLESS: I, (Parent/Guardian) on behalf of myself and/or my minor and/or our heirs, personal representatives and/or assigns, also agree to indemnify and hold Voices Unbound, as well as their affiliates (Journeys Counseling Center, PLLC, Out Loud Productions: Greensboro, LLC, Just Me Podcast, LLC), parents, subsidiaries, assigns, partners, attorneys, employees, independent contractors, shareholders, directors, producers, or any other person/entity associated in any way with the ownership, operation or affiliation with the creation, production or distribution of Voices Unbound-related marketing content on any website owned by (Voices Unbound, Journeys Counseling Center, PLLC, Out Loud Productions: Greensboro, LLC, Just Me Podcast, LLC), harmless from any and all claims, causes of actions, lawsuits, arbitrations or proceedings as well as from any expenses, judgments, costs, fees, damages, expenses and/or liabilities, including attorneys' fees incurred in defending or prosecuting any such claims brought against Voices Unbound as the result of my or my minor's participation ("Participant") in the Activities.
3. RELEASE/WAIVER: In consideration for being permitted to participate in the Activities, I, on behalf of myself and/or my minor and/or our heirs, personal representatives and assigns HEREBY RELEASE, WAIVE AND DISCHARGE Voices Unbound, Journeys Counseling Center, PLLC, Out Loud Productions: Greensboro, LLC, Just Me Podcast, LLC from any and all liability associated with or related to my or my minor's participation in the Activities and agree NOT TO SUE for any reason resulting from or associated with my or my minor's participation in the Activities. This waiver and release is intended to include all claims for injuries, accidents, illnesses, or property loss, whether known or unknown or anticipated or unanticipated, which are in any way related to or associated with the Activities.

4. NO INSURANCE: I, on behalf of myself and/or my minor, acknowledge that Voices Unbound, Journeys Counseling Center, PLLC, Out Loud Productions: Greensboro, LLC, Just Me Podcast, LLC does not carry insurance on behalf of myself or my minor.

5. LEGAL RIGHTS: I, on behalf or myself and/or my minor, understand and acknowledge that I/we are surrendering valuable legal rights in this agreement.

6. SEVERABILITY: I, on behalf or myself and/or my minor, understand and expressly agree that this agreement is intended to be as broad and inclusive as permitted by the law of the State for which it is used and that if any portion of this agreement is held invalid, it is agreed that the balance of the agreement shall continue in full force and effect and that whatever portion is held invalid shall be interpreted and Out Loud Productions GSO Volunteer Agreement construed to afford as much protection to Voices Unbound, Journeys Counseling Center, PLLC, Out Loud Productions: Greensboro, LLC, Just Me Podcast, LLC as permitted by the applicable law.

I am the parent and/or legal guardian of the minor participant. I have read this agreement thoroughly and understand all of the terms. I understand that I am surrendering legal rights on behalf of the minor and myself. I, on behalf of myself and my minor, agree to be bound by all of the terms of this agreement and also give my consent to allow my minor to participate in the Activities described herein. I release and agree to indemnify and hold harmless the Releasees from any kind and all liabilities incident to my minor child's involvement or participation in this 3 day workshop as provided above, even if arising from the negligence of the releases, to the fullest extent permitted by law.
Participants Name Print
Parent/Guardians Name Print
Relationship to Participant
Parent/Guardians Signature

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