YAWP SATURDAY Spring 2019 Parent/Guardian Consent Form

YAWP 2019 Parent/Guardian Consent Form

Student/Teen Information
Student's Full Name*

First NameMiddle (optional)Last Name
Student E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student Cell Phone Number*

Area CodePhone Number
Student date of birth*

MonthDayYear
Date

Parent/ Guardian Information
Parent/ Guardian Full Name*

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

First NameLast Name
Emergency Contact Email
Emergency Contact Cell Number*

Parent/Guardian Consent and Release

Authorization to Participate. I, the undersigned, certify that I am the parent or legal guardian of the above referenced teenager (“My Teen”). Unless and until my consent is revoked, I hereby authorize My Teen to participate in any and all YAWP events and classes hosted by GrubStreet Inc. (“GrubStreet”) for which My Teen registers (“YAWP Programs”). I understand that I am responsible for My Teen’s actions, that My Teen is expected to abide by all GrubStreet rules and policies, and that failure to do so may result in My Teen’s dismissal from YAWP Programs.

Program Content. I understand that YAWP Programs include a wide range of creative content that address subjects including race, religion, gender, sex, and sexual orientation. Some creative content may be considered by some people to be offensive, crude, or otherwise objectionable. I understand and agree that GrubStreet is not responsible for censoring content generated in connection with YAWP Programs.

Supervised Excursions/Unsupervised Breaks. I hereby authorize My Teen to participate in supervised excursions in and around the Boston area. These excursions may include, among other destinations, the Boston Public Garden, Boston Common, Boston Public Library, and Copley Square areas. I also authorize My Teen to leave GrubStreet’s physical facilities for unsupervised breaks including lunch breaks.

Release and Indemnification. I understand that there are certain risks associated with My Teen’s participation in YAWP Programs including, for example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death. By typing my full name in the signature box below, I hereby agree to assume all such risks, whether known or unknown to me at this time. In consideration of My Teen being given the opportunity to participate in and benefit from YAWP Programs, I hereby agree on behalf of myself and My Teen to release and hold harmless GrubStreet, its officers, directors, board members, faculty, employees, agents, representatives, and each of their successors and assigns (“GrubStreet Entities”) from any and all claims, loses, expenses, costs, or liabilities of any nature that may result from or in connection with My Teen’s participation in the YAWP Program. I further agree to indemnify, defend, and hold harmless GrubStreet and all GrubStreet Entities from and against any and all claims, losses, expenses, costs, or liabilities of any nature that a third party may have against GrubStreet and/or GrubStreet entities that are based on, arise out of, or involve My Teen’s participation in YAWP Programs.

Right to Revoke Consent. I understand that I can revoke this consent at any time by notifying GrubStreet by email at YAWP@grubstreet.org. I understand and agree that if I revoke consent, my revocation request will be not become effective until I receive a reply email from GrubStreet confirming receipt of my revocation request. I UNDERSTAND AND AGREE THAT REVOCATION OF MY CONSENT DOES NOT REVOKE THE ABOVE RELEASE AND INDEMNIFICATION WITH RESPECT TO MY TEEN’S PARTICIPATION IN ANY YAWP PROGRAMS PRIOR TO THE EFFECTIVE DATE OF REVOCATION.
Parent or Guardian: If you agree to the above consent and release, please type your full name in the signature box below.

Media Release (Optional). I hereby authorize GrubStreet, its employees, agents, and representatives to take photographs, videotapes, and other recordings of My Teen in connection with My Teen’s participation in YAWP Programs (“Recordings”). I acknowledge and agree that GrubStreet will own all rights to such Recordings.

I hereby authorize GrubStreet, its employees, agents, representatives and their successors and assigns to publish, use, reproduce, modify, adapt, license, sublicense, distribute, sell, perform, translate, and display the Recordings (including adaptations or derivative works based on the Recordings) for any purpose and in any manner or medium now existing or hereafter developed. This may include, for example, use of such Recordings on GrubStreet’s web site or in GrubStreet promotional materials or advertisements.

I acknowledge and agree that neither I nor My Teen has any right to inspect the Recordings or to be compensated in any way for the use of the Recordings. I further agree on behalf of myself and My Teen to release and hold harmless GrubStreet, its officers, directors, board members, faculty, employees, agents, representatives, and each of their successors and assigns from any and all claims, loses, expenses, costs, or liabilities of any nature that may result from or arise in connection with the Recordings.
Parent or Guardian: If you agree to the above media release, please type your initials in the signature box below.

Please list any relevant allergies your child may have or special accommodations your child may need:
Please make sure your form is complete before clicking "Submit." Once your form is submitted, you will be taken to the confirmation page. You and the student will also receive a confirmation email.
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YAWP 2019 Parent/Guardian Consent Form