THE QUEEN'S ACADEMY 2026 Summer Program Waiver form

THE QUEEN'S ACADEMY 2026 SUMMER PROGRAM.
Participant Release Waiver & Media Release Form
This form must be completed and signed by the parent or legal guardian of each accepted participant before the first day of the program. Please read each section carefully.
PARTICIPANT INFORMATION
Participant Full Name:
Date of Birth:

MonthDayYear
Date
Age:
School:
Grade (Fall 2026):
Address:
City / State / ZIP:
Participant Phone (if applicable):
Format: (000) 000-0000.
PARENT / LEGAL GUARDIAN INFORMATION
Parent / Guardian Name:
Relationship to Participant:
Phone (Primary):
Format: (000) 000-0000.
Phone (Secondary):
Format: (000) 000-0000.
Email:
example@example.com
Home Address (if different):
EMERGENCY CONTACT (other than parent/guardian)
Name:
Relationship:
Phone:
Format: (000) 000-0000.
MEDICAL INFORMATION & ALLERGIES
Allergies (food, medication, environmental):
Current medications:
Medical conditions we should be aware of:
Insurance Provider:
Policy #:

SECTION 1 — RELEASE OF LIABILITY & ASSUMPTION OF RISK
I, the undersigned parent or legal guardian of the above-named minor participant (the "Participant"), hereby grant permission for the Participant to attend and participate in The Queen's Academy 2026 Summer Program (the "Program"), a program of The Queen's Foundation, a Texas 501(c)(3) nonprofit organization (EIN: 88-3000686).
I understand and acknowledge that the Program is held at SheSpace (2799 Katy Freeway, Suite 250, Houston, TX 77007) and other off-site locations including but not limited to community service sites and group outing destinations, and that participation involves travel, interactions with guest speakers, group activities, and physical movement.
Assumption of Risk: I voluntarily accept all risks associated with the Participant's involvement in the Program, including but not limited to risks of injury, illness, property loss, or other harm arising from Program activities, transportation to and from Program locations, and interaction with other participants and staff.
Release of Claims: In consideration of the Participant's acceptance into the Program, I, on behalf of myself, the Participant, and our respective heirs and legal representatives, hereby release, waive, and discharge The Queen's Foundation, its officers, directors, employees, volunteers, agents, partner organizations, venue sponsors (including SheSpace), and program sponsors from any and all claims, liabilities, damages, or causes of action arising from or related to the Participant's participation in the Program, except those caused by gross negligence or willful misconduct.
I have read this release carefully and sign it of my own free will.
Parent/Guardian Signature:
Printed Name:
Date:

MonthDayYear
Date
SECTION 2 — EMERGENCY MEDICAL AUTHORIZATION
In the event of a medical emergency involving the Participant during Program hours or activities, and if the parent or legal guardian cannot be reached immediately, I authorize The Queen's Foundation staff to:
- Seek emergency medical care for the Participant from a qualified medical professional or facility;
- Transport or arrange transport of the Participant to a hospital or urgent care facility as needed;
- Administer basic first aid;
- Contact emergency services (911) if warranted.
I understand that I am financially responsible for any medical care provided to the Participant and that The Queen's Foundation is not responsible for the cost of such care. Every reasonable effort will be made to contact me as soon as possible.
Parent/Guardian Initials:
Date:

MonthDayYear
Date

SECTION 3— PHOTO & MEDIA RELEASE
I grant The Queen's Foundation and its representatives permission to take, use, and publish photographs, video recordings, audio recordings, and other visual or audio materials of the Participant during the Program. I understand that these materials may be used for purposes including but not limited to:
- Promotional materials such as flyers, brochures, and newsletters;
- The Queen's Foundation website (queens-foundation.org);
- Social media platforms (Instagram, Facebook, etc.);
- Grant applications, donor reports, and fundraising materials;
- Press releases and media coverage of the Program.
I understand that the Participant's full name will not be published alongside any images or recordings without separate written permission. First names or initials only may be used. I waive any right to inspect or approve the finished materials and any compensation for their use.
Please initial ONE of the following:
FINAL ACKNOWLEDGMENT & SIGNATURE
By signing below, I confirm that:
- I am the parent or legal guardian of the Participant named on this form;
- I am at least 18 years of age and legally able to sign this form;
- I have read and understood all three sections of this form;
- The information I have provided is accurate and complete to the best of my knowledge.
Parent/Guardian Signature:
Printed Name:
Date:

MonthDayYear
Date
Participant Signature:
(Age 13+)
Printed Name:
Date:

MonthDayYear
Date
The Queen's Foundation 501(c)(3) Nonprofit EIN: 88-3000686 admin@queens-foundation.org (281) 759-2360-queens-foundation.org
Should be Empty:

THE QUEEN'S ACADEMY 2026 SUMMER PROGRAM.

Participant Release Waiver & Media Release Form

PARTICIPANT INFORMATION

PARENT / LEGAL GUARDIAN INFORMATION

EMERGENCY CONTACT (other than parent/guardian)

MEDICAL INFORMATION & ALLERGIES

SECTION 1 — RELEASE OF LIABILITY & ASSUMPTION OF RISK

SECTION 2 — EMERGENCY MEDICAL AUTHORIZATION

SECTION 3— PHOTO & MEDIA RELEASE

FINAL ACKNOWLEDGMENT & SIGNATURE