YAWP SATURDAY/Slam 2018 Parent/ Guardian Consent Form

YAWP Fall 2018 Parent/ Guardian Consent Form
Student/ Teen Information
Student's Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail*
example@example.com
Student Cell Phone Number*

Area CodePhone Number
Student will be commuting by (select all that apply):*

Car (driving themselves)Drop off/ pick upT/ SubwayBusWalking/ Biking

Parent/ Guardian Emergency Contact Information
Parent/ Guardian Full Name*

First NameLast Name
Parent/ Guardian Daytime Phone Number*
Parent/ Guardian Alternate Phone Number
Parent/ Guardian Email*
Emergency Contact Full Name*

First NameLast Name
Emergency Contact Phone Number*
Emergency Contact Alternate Phone Number
Emergency Contact Email

Parent Guardian Consent Waiver
I, the undersigned parent or guardian of the above referenced minor (“Participant”), do hereby consent to said child’s participation in the*
hosted by Grub Street Inc. (“GrubStreet”). I understand that I am responsible for the actions of my child, and agree to defend, hold harmless, indemnify and release GrubStreet, Inc., its employees, agents and assigns, from any and all claims and liabilities that may result from or in connection with such minor’s participation in the YAWP Program.
Type your full name in the signature box to indicate your consent.*
Additionally, I, the undersigned parent or guardian of the above referenced minor ("Participant"), do hereby grant my child permission to attend supervised excursions to the surrounding Boston Public Garden, Boston Common and Copley Square areas.
Type your initials in the signature box to indicate your consent to the above statement.*
Additionally, I, the undersigned parent or guardian of the above referenced minor ("Participant"), do hereby grant my child permission to leave GrubStreet (162 Boyston Street, Floor 5) for unsupervised lunch breaks.
Type your initials in the signature box to indicate your consent to the above statement.*
Additionally, I, the undersigned parent or guardian of the above referenced minor ("Participant"), understand that Grub Street is not responsible for censoring any creative content generated or distributed during the YAWP program. Students will also evaluate themselves and the program through surveys.
Type your initials in the signature box to indicate your consent to the above statement*
Lastly, I, Parent/Legal Guardian of the above referenced minor ("Participant") hereby grant GrubStreet, Inc., its employees, agents and assigns, permission to take photographs, videotape, or digital recordings of the above-named child, and to use these in any and all forms, media, and manners, now or hereafter known.

I give unrestricted permission for images, videos, and recordings of the child to be used in print, video, digital and internet media. I agree that these images and/or recordings may be used for a variety of purposes, and that these images and/or recordings may be used without further notifying me.

I further acknowledge that I will not be compensated for these uses and GrubStreet, Inc. owns all rights to the images, videos and recordings, and to any derivative works created from them.

I waive any right to inspect the uses of any printed or electronic copy. I hereby release and relieve GrubStreet, Inc. and its employees, agents and assigns from any claims, damages or liabilities, known or unknown, arising out of the use of this material.

I certify that I have read the Media Release For Media Recording or Image and fully understand its terms and conditions.
Type your initials in the signature box below to indicate your consent to the above statement.*
Please make sure your application is complete before clicking "Submit." Once your application is submitted, you will be taken to the confirmation page. You will also receive a confirmation email.
Should be Empty:

YAWP Fall 2018 Parent/ Guardian Consent Form