PARENTAL/GUARDIAN CONSENT & LIABILITY WAIVER FORM
(Download file on the bottom of this page or print this page)
Waiver form for Social Events:
Westchester Sign Language Center of The Guidance Center
PARENTAL/GUARDIAN CONSENT & LIABILITY WAIVER FORM
FOR SOCIAL EVENTS
PARTICIPANT’S NAME: _________________________________________
BIRTH DATE: _______________________ SEX: __________________
PARENT/GUARDIAN’S NAME: _______________________________________
HOME ADDRESS: _________________________________________________
HOME PHONE: ________________ CELL PHONE: _____________________
I, (name of parent or guardian) _________________________, grant permission for my child (name of child) _________________________, to participate in the Westchester Sign Language Center’s social events. This class will take place under the guidance and direction of the Westchester Sign Language Center (WSLC) employees.
I, (name of parent or guardian) _________________________, will not hold WSLC liable for any incident.
I, (name of parent or guardian) _________________________, am aware that WSLC is not responsible for any lost or stolen personal items.
Location of the class: 2 Central Ave Tarrytown, NY 10591
Duration of the class: 2 hours, once a week for 5 weeks
Signature: _______________________________ Date: ___________________
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to send my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
NAME & RELATIONSHIP: ___________________________
HOME PHONE: ___________________ CELL PHONE: __________________
FAMILY DOCTOR: ____________________ PHONE: _____________________
- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -
VIDEO/PHOTOGRAPHY CONSENT
Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Office of the Westchester Sign Language Center of The Guidance Center. (Participants would not be identified, however, without specific written consent) Please note that the Office has no control over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate(s).
I hereby expressly assign to the Westchester Sign Language Center of The Guidance Center, and to all it’s agents all the rights, title and interest in, and to all photos/ videotape recordings made by such in which my child appears and/or his/her voice is used in and in connection with the videotaping of this event. I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or any distribution of said photos/ videotape without limitation for any purpose whatsoever; and I further waive all rights to any compensation for my child’s appearance or participation in the photographs/videotape recordings.
______________________________ ___________________
Parent/Guardian (Print name) Date
______________________________
Parent/Guardian (Signature)
_____________________________________________________________________________________________
Waiver form for ASL classes:
Westchester Sign Language Center of The Guidance Center
PARENTAL/GUARDIAN CONSENT & LIABILITY WAIVER FORM
FOR ASL CLASSES
PARTICIPANT’S NAME: _________________________________________
BIRTH DATE: _______________________ SEX: __________________
PARENT/GUARDIAN’S NAME: _______________________________________
HOME ADDRESS: _________________________________________________
HOME PHONE: ________________ CELL PHONE: _____________________
I, (name of parent or guardian) _________________________, grant permission for my child (name of child) _________________________, to participate in the Westchester Sign Language Center’s ASL classes. This class will take place under the guidance and direction of the Westchester Sign Language Center (WSLC) employees.
I, (name of parent or guardian) _________________________, will not hold WSLC liable for any incident.
I, (name of parent or guardian) _________________________, am aware that WSLC is not responsible for any lost or stolen personal items.
Location of the class: 2 Central Ave Tarrytown, NY 10591
Duration of the class: 2 hours, once a week for 5 weeks
Signature: _______________________________ Date: ___________________
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to send my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
NAME & RELATIONSHIP: ___________________________
HOME PHONE: ___________________ CELL PHONE: __________________
FAMILY DOCTOR: ____________________ PHONE: _____________________
- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -
VIDEO/PHOTOGRAPHY CONSENT
Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Office of the Westchester Sign Language Center of The Guidance Center. (Participants would not be identified, however, without specific written consent) Please note that the Office has no control over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate(s).
I hereby expressly assign to the Westchester Sign Language Center of The Guidance Center, and to all it’s agents all the rights, title and interest in, and to all photos/ videotape recordings made by such in which my child appears and/or his/her voice is used in and in connection with the videotaping of this event. I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or any distribution of said photos/ videotape without limitation for any purpose whatsoever; and I further waive all rights to any compensation for my child’s appearance or participation in the photographs/videotape recordings.
______________________________ ___________________
Parent/Guardian (Print name) Date
______________________________
Parent/Guardian (Signature)
BIRTH DATE: _______________________ SEX: __________________
PARENT/GUARDIAN’S NAME: _______________________________________
HOME ADDRESS: _________________________________________________
HOME PHONE: ________________ CELL PHONE: _____________________
I, (name of parent or guardian) _________________________, grant permission for my child (name of child) _________________________, to participate in the Westchester Sign Language Center’s ASL classes. This class will take place under the guidance and direction of the Westchester Sign Language Center (WSLC) employees.
I, (name of parent or guardian) _________________________, will not hold WSLC liable for any incident.
I, (name of parent or guardian) _________________________, am aware that WSLC is not responsible for any lost or stolen personal items.
Location of the class: 2 Central Ave Tarrytown, NY 10591
Duration of the class: 2 hours, once a week for 5 weeks
Signature: _______________________________ Date: ___________________
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to send my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
NAME & RELATIONSHIP: ___________________________
HOME PHONE: ___________________ CELL PHONE: __________________
FAMILY DOCTOR: ____________________ PHONE: _____________________
- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -
VIDEO/PHOTOGRAPHY CONSENT
Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Office of the Westchester Sign Language Center of The Guidance Center. (Participants would not be identified, however, without specific written consent) Please note that the Office has no control over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate(s).
I hereby expressly assign to the Westchester Sign Language Center of The Guidance Center, and to all it’s agents all the rights, title and interest in, and to all photos/ videotape recordings made by such in which my child appears and/or his/her voice is used in and in connection with the videotaping of this event. I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or any distribution of said photos/ videotape without limitation for any purpose whatsoever; and I further waive all rights to any compensation for my child’s appearance or participation in the photographs/videotape recordings.
______________________________ ___________________
Parent/Guardian (Print name) Date
______________________________
Parent/Guardian (Signature)
Downloadable forms:
Parental/Guardian content form for Social Events:
|
Parental/Guardian content form for ASL classes:
|
||||
