JLEFC Positively Me - Spring 2026

By filling out and submitting this form, you are offiically signing up your kiddo for the upcoming Positively Me session! Please note: this is a 2-day event and we ask that all participants commit to attending both days. Friday is a PJ & Pizza Party, from 5:30-8:30. Saturday runs from 10-3 and lunch will be provided.

Participant's Full Name

First NameLast Name

Participant's School & Grade

Participant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant's Date of Birth

Parent / Guardian's Full Name

Relationship to Participant

Parent / Guardian's Contact Number

To be used during the event if necessary

Parent / Guardian's email address

Alternate Contact

Name & Phone Number

Additional Alternate Contact (optional)

Name & Phone Number

Approved pick-up list

The participant will not be released to anyone other than a parent or legal guardian unless thename is listed below, or you send written consent for your child to leave with someone else.This is for the participant’s protection. We may ask for identification if we are unsure of theperson picking up the participant.Please list anyone else who has permission to pick up the participant

Does the participant have any allergies or health issues you'd like us to be aware of? If yes,please describe

Do you give permission for photographs to be taken of the participant to be used for publicrelations materials? (No names or school information will be shared)

The “PositivelyMe!” Program Indemnity/Release of Liability:

As parent/guardian of the participant’s name, I agree for myself, my child, my (our) heirs,

executors, legal guardians and administrators (collectively, the “Releasor”) to indemnify and

hold harmless the Junior League of Eastern Fairfield County and their respective members,

officers, directors, administrators, employees, representatives and agents (collectively, the

“Releasee”) from and against any and all loss, cost, expense, fees (including legal fees),

liability (arising from injury or otherwise), damage, claim, demand, suit, or cause of action, of

any nature whatsoever for any act or omission arising from my child’s participation in this

program and any related activities. On behalf of the Releasor, I further accept the risk of

unforeseen circumstances arising from this program and release, remise, waive and forever

discharge the Releasee from any and all liability (for injury or otherwise), loss, damage, claim,

demand, suit or action arising from my child’s participation in any activities located at,

sponsored by or otherwise coordinated by the Junior League of Eastern Fairfield County

(specifically including this program and any services or performances provided by third party

contractors for this program.

Confidentiality:As a general rule, The Junior League of Eastern Fairfield County and its Releasee will keep

information shared during this program confidential. In some situations, the Releasee is

required by law or by the guidelines of its profession to disclose information without

permission.

Jurisdiction:

This Consent shall be interpreted, construed and enforced in accordance with the laws of the

State of Connecticut. If any legal action arises out of or is in any way connected with my

child’s participation in this program, I consent to the exclusive jurisdiction of any State or

Federal Court located in the State of Connecticut having subject matter jurisdiction and waive

any objection to such venue or convenience of such forum.

In case any one or more of the provisions contained in this Consent shall for any reason be

held to be invalid, illegal or unenforceable in any respect, such invalidity, illegality or

unenforceability shall not affect any other provision hereof, and this Consent shall be

construed as if such invalid, illegal or unenforceable provision had never been contained

herein.

I HAVE READ THIS CONSENT, I FULLY UNDERSTAND ITS TERMS AND THEIR LEGAL

EFFECT, AND I HEREBY SIGN IT FREELY AND VOLUNTARILY. I FURTHER STATE THAT I

AM THE PARENT/GUARDIAN OF THE CHILD NAMED HEREIN, THAT I AM COMPETENT

TO SIGN THIS CONSENT, AND THAT I CONSENT TO MY CHILD’S PARTICIPATION IN

THIS PROGRAM IN CONSIDERATION OF THE TERMS SET FORTH HEREIN

Guardian Name:

Guardian Signature

One last thing!How did you hear about the PositivelyMe! program?