If, in the event of a medical or other emergency, I am unable to be reached by telephone at my telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.

I hereby grant Planet Smilez, Delta Dental Foundation and its affiliate partners the irrevocable right and permission to use photographs and/or video recordings of my child taken during Planet Smilez dental outreach events for use in promotional materials, and educational content including but not limited to newsletters, brochures, website content, social media, and other publications. I understand and agree that these materials may be used for non-commercial purposes and that Planet Smilez will not provide compensation for the use of these materials. I hereby release and discharge Planet Smilez from any and all claims, liabilities, demands, actions, causes of action, costs, and expenses arising out of or in connection with the use of the photographs and/or video recordings. I am at least 18 years of age, or if under 18, my parent or legal guardian has read and agreed to the terms of this consent form.

Participants are responsible for securing their own rides to and from Planet Smilez Discovering Dentistry Symposium.

Participants will be offered mentorship and career guidance opportunities. This will include dentistry pathway education and immersive educational activities related to the field of dentistry.

The child named above is in good health and has no physical or medical limitations that would cause the activities as described above to be detrimental or dangerous to the child. Parents/guardians should specify allergies and medical problems in section above.

By signing this Consent and Release Form, I acknowledge and agree that Planet Smilez, Inc. may share my child’s name and parent/guardian contact information with affiliated dental schools, educational institutions, nonprofit organizations, community partners, sponsors, and professional organizations that collaborate with Planet Smilez for the purpose of providing educational, mentorship, scholarship, career exploration, volunteer, or enrichment opportunities related to dentistry, oral health, and health professions. This authorization shall remain in effect for the duration of my child’s participation in Planet Smilez programming and related alumni engagement initiatives unless revoked in writing. By signing this consent form, I acknowledge and agree that my child may participate in the Planet Smilez Mentorship Certificate Program, which includes six (6) structured virtual mentorship sessions conducted via Zoom following the initial in-person Discovering Dentistry Symposium. I understand that these sessions are educational in nature and may include interactive discussions, presentations, career guidance, and capstone activities designed to support my child’s academic and professional development in oral health careers. I authorize Planet Smilez, Inc. and its representatives, volunteers, and affiliated partners to facilitate my child’s participation in these virtual sessions and acknowledge that reasonable safeguards will be implemented to promote a safe and supervised online learning environment. I understand that participation requires reliable internet access and appropriate technology, and I accept responsibility for ensuring my child’s availability and supervision as appropriate during virtual sessions.

I confirm that I am the legal parent/guardian of the above-named child and give my consent for their participation in the activities outlined above. I understand that these activities may involve a risk of physical injury but specifically request that my child be allowed to participate. Additionally, I consent to my child's participation in de-identified surveys and pre- and post-feedback surveys, which are all anonymous. I also provide consent to participate in de-identified surveys to provide feedback on parental informational sessions about oral health career paths for their children. Planet Smilez Inc, the Delta Dental Foundation and participating community host partners will have access to this anonymous data as sponsors for the event. By signing this form, I voluntarily agree to have my child participate in a research and evaluation study conducted by Planet Smilez Inc. The study aims to assess the effectiveness of our programs in promoting oral health awareness, education, and community engagement. Participation may include completing surveys, participating in interviews or focus groups, or providing feedback about our programs. All information collected will remain confidential and will only be used to improve our programs and evaluate its impact. Participation is entirely voluntary, and you may withdraw at any time without penalty or impact on your involvement with Planet Smilez Inc. For questions about the study or your rights as a participant, please contact the Research Coordinator, Dr. Lauren Gritzer at dr.laurengritzer@gmail.com. By signing below, you acknowledge that you have read and understood this consent form and agree to participate.

I/We understand that Planet Smilez Inc. does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to and authorize the activity supervisor(s) to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s).

I release and waive, and further agree to indemnify, hold harmless or reimburse Planet Smilez, the individual members, agents, employees and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses, damages or injuries arising out of, during, or in connection with the child's participation in the activities (including all forms of transportation) or the rendering of emergency medical procedures or treatment, if any.

Please note that space is limited to 60 participants. You will receive a confirmation once your child’s spot is secured. For any questions please contact Dr. Kathryn Pawlak at kathryn.pawlak@planetsmilez.org or 732-991-5626. Thank you!