SCHOOL RECORDS RELEASE FORM

First Name*   Last Name*   , is a Participant (“Participant”) in the CNX MENTORSHIP ACADEMY (“Program”), a program sponsored by CNX FOUNDATION and CNX Resources Corporation and/or its subsidiaries and affiliates.

As part of providing continuity in services to the Participant without duplication and to obtain understanding of presenting needs to provide appropriate services and support through collaborative work between home, school, and the community, the Program may from time to time require information related to the Participant’s performance, records, and history at their School.

* * * *
To be completed by parent/guardian of Participant:

As parent/guardian of Participant, I hereby authorize the release of any information pertaining to Participant held by   *   School District relating to Participant’s academic, special education, medical, social, behavioral, and/or psychological circumstances, history, or records to the Program upon request made by the Program.
I am the parent or legal guardian of the minor named above. I have the legal right to consent to and, by signing below, I hereby do consent in all respects to the terms and conditions of this release. This release applies from the date below to the end of the current school year.

Signature of Parent/Guardian:   Signature*   
Print Name of Parent/Guardian:   First Name*   Last Name*   
Date:   Date*   School Year: 2026-2027

* * * *
To be completed by Participant:

I hereby authorize the release of any information pertaining to me held by     *    School District relating to my academic, special education, medical, social, behavioral, and/or psychological circumstances, history, or records to the Program upon request made by the Program. This release applies from the date below to the end of the current school year.

Signature of Participant:   Signature*   
Print Name of Participant:   First Name*   Last Name*   
Date:   Date*   School Year: 2026-2027
      

INFORMED CONSENT, RELEASE AGREEMENT, AND AUTHORIZATION
Participant name:   First Name*   Last Name*   
I understand that participation in activities conducted during the CNX Academy Program (the “Activities”) involves the risk of personal injury, including death, resulting from the physical, mental, and/or emotional activities and circumstances involved in the Activities offered. Information about those Activities may be obtained from the venue or Activities coordinators. Such participation also encompasses transportation to and from the Activities without the supervision of parent or guardian, the means of which may include public transportation, taxi, ride-sharing services, and/or transportation provided by the Activities in the form of shuttle service or carpooling via automobile driven by an adult individual associated with the Activities. I also understand that participation in these Activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct.

In case of an emergency involving me / my child, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or adult leader of the program Activities (“Program Leader”). In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the Program Leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or the administration of medication for me or my child. I hereby give permission to CNX to disclose the medical conditions and allergies listed below to Medical providers in order to administer treatment to Participant, and Medical providers are authorized to disclose protected health information to the Program Leader and other authorized CNX Foundation and/or CNX Resources Corporation, and their respective affiliates and assigns (collectively "CNX") personnel and/or any physician or health-care provider involved in providing medical care to the participant. Protected Health Information/ Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., including examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program Activities.

I have carefully considered the risk involved and hereby give my informed consent for my child to participate in all Activities offered in the program. I further authorize the sharing of the information on this form with any CNX volunteers and employees and the Activities volunteers or professionals who need to know of medical conditions that may require special consideration in conducting the Activities.

With appreciation of the dangers and risks associated with programs and Activities, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against CNX, Program Leader, the Activities coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or the Activities.

I / on behalf of myself and my youth Participant, hereby consent to myself / my youth Participant receiving communications from the Activities and/or CNX via electronic means, including text messages to my / my youth Participant’s mobile devices.

I also hereby assign and grant to CNX as well as their authorized representatives thereof, the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child at all program Activities, and I hereby release CNX, the Program Leader, the Activities coordinators, and all employees, volunteers, related parties, or other organizations associated with the Activities from any and all liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of CNX, and I specifically waive any right to any compensation I may have for any of the foregoing.

NOTE: Due to the nature of programs and Activities, CNX and Program Leader cannot continually monitor compliance of program participants, or any limitations imposed upon them by parents or medical providers. However, so that the Program Leader and other Activities coordinators can be as familiar as possible with any limitations, list any restrictions imposed on a child participant in connection with programs or Activities below.

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in the Activities. The participant has permission to engage in the program Activities, except as specifically noted by me or the health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.




Contact Information of Authorizing Parent/ Guardian of Youth Participant:

Name:   First Name*   Last Name*   
Relationship to youth:   *   
Telephone Number:      Area Code*   Phone Number*   

Additional Emergency Contact for Participant
Name:   First Name*   Last Name*   
Relationship to youth:   *   
Telephone Number:   Area Code*   Phone Number*   







Medical Conditions that may Place Participant at Increased Risk of Harm: None/ Does not Apply
List all that apply:   *   



Environmental Allergies: None/ Does not Apply
List all that apply:   *   



Food or Medication Allergies: None/ Does not Apply
List all that apply:   *   









Participant Signature:   Signature*   
Date:    Date*           

Parent/ guardian Signature:   Signature*   
Date:     Date          

CNX ACADEMY (“Program”), a program sponsored by CNX Resources Corporation and/or its subsidiaries and affiliates and CNX FOUNDATION (collectively "CNX"), desires to potentially use and publicize the name, likeness, voice and other personal characteristics and private information of the individual named below ("I" or "me") obtained from CNX Academy program activities (“Activities”) for advertising, promotion, and other commercial and business purposes. In exchange for the intangible value I will gain by participating in CNX's Activities, the receipt and sufficiency of which I hereby acknowledge, I give CNX my permission for such use and publicity for such purposes, according to the terms and conditions set forth in this Participant Publicity Waiver and Release (“Agreement”).

I hereby irrevocably consent to the use of my name and likeness, including my performance, voice
and image in any form by CNX and its parents, affiliates, subsidiaries, related companies, successors, licensees or designees and others acting on its behalf (“Representatives”) for the purpose of advertising and promotion in any media, throughout the world in perpetuity, including but not limited to, on the world wide web. If I am featured in any and all such materials created by or on behalf of CNX that incorporate any of the foregoing ("Materials”), in any manner, I hereby irrevocably consent to the CNX and its Representatives’ use as set forth above.

I agree that CNX shall own all right, title and interest to the Materials (including all content and all rights embodied therein) and that it may exploit, edit, modify, and distribute the Materials, without limitation, and without compensation, further permission or notification to me. I hereby waive any inspection or approval of use. I also waive and release CNX from any claims, including but not limited to, based upon invasion of privacy, right of publicity, defamation, false endorsement, or claim of visual or audio alteration or faulty mechanical reproduction.

No promise or representations of any kind have been made to me.
THIS AGREEMENT PROVIDES CNX WITH YOUR ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING CNX TO PUBLICIZE AND COMMERCIALLY UTILIZE YOUR NAME, LIKENESS, AND OTHER PERSONAL CHARACTERISTICS AND PRIVATE INFORMATION AS SET OUT ABOVE. BY SIGNING, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT YOU ARE GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE CNX.

Signature of Participant   Signature*   
Name of Participant   First Name*   Last Name*   Date:   Date*   

I am the parent or legal guardian of the minor named above. I have the legal right to consent to and, by signing below, I hereby do consent in all respects to the terms and conditions of this Publicity Waiver and Release and agree that both the minor and I shall be bound by all of its terms and conditions.

Signature of Parent/Guardian:   Signature*   Date:   Date*   
Name of Parent/Guardian:   First Name*   Last Name*