Family Waiver Form | Friendship Circle of Charlotte

Special Friend Information

Name*

Date of Birth*

Gender*

Male
Female

Email*

Parent Name*

Parent Address*

Parent Home Phone*

Parent Cell Phone*

Agreements & Permissions

As a participant in Friendship Circle of Charlotte:*

I understand that Friendship Circle will introduce my child to a teenage friend.
I understand that it is necessary for me, as a parent/guardian, to assume full oversight and supervision responsibilities with regards to all activities Friendship Circle's assigned Teen Friend(s) share(s) with my child in connection with his/her participation in Friendship Circle.
I understand that if someone gets hurt, or some other incident occurs during a Friendship Circle program, it is my responsibility to immediately report the occurrence to Friendship Circle staff.
I agree to respect the privacy of all participants of Friendship Circle and to keep personal information confidential.

Commitment to Everyone’s Safety and Well-Being*

I will comply with Friendship Circle's Commitment to Safety and Well-Being as outlined below.

Friendship Circle of Charlotte provides unique opportunities for Teen Friends, Special Friends, and their families to enrich each other's lives, as well as their own. In doing so, most participants will encounter new and sometimes
challenging situations. Thus, it is imperative to set expectations at the beginning so they are clear for everyone involved.

As a participant in Friendship Circle of Charlotte:

• I understand that participation in any and all activities and programs is entirely voluntary and requires everyone to abide by applicable rules and standards of conduct.
• I understand that photographs can be private and sensitive and should not be shared without permission of the people in the photo.
• I will not use or possess any illegal drug or controlled substances at any time, including at Friendship Circle events or programs.
• I will not use any alcohol or tobacco products at Friendship Circle events or programs.
• I will not bring any weapons, firearms or other dangerous items to any Friendship Circle events or programs.
• I will not participate in any activity that I believe my child cannot perform in accordance with Friendship Circle’s instructions or in a safe manner.
• If I observe any significant hazard during my child’s participation in any event or program, I will have my child stop participating in the event and inform Friendship Circle staff of such hazard immediately.
• I agree to abide by and perform everything stated in the Parent Handbook in its entirety.

Medical Attention Release*

I agree to the treatment policy outlined below.

I agree that in case of emergency, I understand every effort will be made to contact my child's emergency contact. In the event they cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication. I hereby give my permission that paramedics may transport my child to the nearest hospital, if necessary.
I authorize medical providers to disclose to the adult in charge any 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.

Waivers

Liability Waiver*

I understand and agree to waive liability as outlined below.

I (hereinafter defined as my child and I) understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and I have agreed to participate in these activities. I also understand that participation in these activities is entirely voluntary and requires participants to abide and be bound by all applicable rules and policies as set forth in Friendship Circle of Charlotte's Handbook, as it may be modified from time to time and any additional rules pertaining to specific events. I understand that Friendship Circle of Charlotte is independently owned, operated and controlled. I hereby release, waive all claims, and agree to hold harmless Friendship Circle of Charlotte and its employees, directors, officers, contractors, and volunteers as well as its affiliates and all other organizations associated with Friendship Circle of Charlotte from any and all claims or liability arising out of this participation.

Assumption of Risks*

I acknowledge, understand, agree and appreciate the risks outlined below, and others, that are inherent in Friendship Circle. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

I fully acknowledge participation in Friendship Circle of Charlotte, including transportation thereto, may pose some risk and, fully realizing the risks of participating in Friendship Circle, I FULLY ASSUME THE RISKS ASSOCIATED WITH SUCH PARTICIPATION including, but not limited danger of medical emergencies such as serious physical and/or mental trauma, injury or death associated with Friendship Circle of Your Town. Further, I acknowledge that such inherent risks from participation cannot be eliminated regardless of the care taken to mitigate such risk. The specific risks vary from one activity to another, but the risks include, but are not limited to, the following: minor injuries such as scratches, bruises, contusions, and sprains; major injuries such as eye injury or loss of sight, bone, joint or spinal cord injuries, strokes, heart attacks, and concussions; and catastrophic injuries such as paralysis or death.

Waiver*

I fully release Friendship Circle from any liability as outlined below.

In consideration of being permitted to participate in Friendship Circle of Charlotte, I and my successors, assigns, heirs, next of kin, executors, administrators, and personal representatives, do hereby release, waive, discharge, and covenant not to sue Friendship Circle of Charlotte for liability from any and all claims including, but not limited to, the negligence of Friendship Circle of Charlotte resulting in personal injury, accidents, or illnesses (including death) and property loss arising from, but not limited to activities.

Transportation*

I hereby give permission to Friendship Circle of Charlotte to transport my child to and from any excursion while my child is in their care.
I will not hold Friendship Circle of Charlotte liable for any accidents, injuries, damage, or fatalities which may occur in transit to/from the aforementioned event.
I waive all rights to sue Friendship Circle of Charlotte for any of the above-mentioned incidents which may occur in transit, or at Friendship Circle.

Scope of Release*

I have carefully read this agreement and fully understands its contents.

I am aware that this is a release of liability and is expressly intended to cover and include all claims, past, present or future, known or unknown, which can or may ever be asserted by me, my child and each of our successors or assigns as the result of participants use of the property, or the effects or consequences thereof. I understand and agree that this agreement covers and includes all claims of every kind or nature, past, present or future, known or unknown, suspected or unsuspected.

Photo Permissions

Photo/Media Release

I agree to grant Friendship Circle of Charlotte and its authorized agents the rights and permissions outlined below.

I hereby freely and irrevocably grant to Friendship Circle of Charlotte and its authorized agents, the absolute right and permission to copy, exhibit, copyright, use, take, distribute and/or publish photographic likeness, name, voice, and/or image made in relation to Friendship Circle in photographs, video and in any and all other media, in which I may be included in whole or in part, or in composite form in conjunction with my name and other identifying information, or reproductions thereof in color or otherwise, made through any media for art, print, web, social media, advertising, film, telecast or any other lawful purpose whatsoever.

I hereby give permission for my child's photo to be taken for internal use.*

Yes
No

I hereby give permission for my child's photo to be used for publicity purposes (i.e brochures, newspaper)*

Yes
No

I hereby give permission for my child's photo to be posted on Friendship Circle's Website, Facebook, and other Social Media pages*

Yes
No

Modification Waiver*

I agree to the following:

No change or modification of this Agreement shall be valid unless such change or modification is in writing and signed by each of the parties hereto. No waiver of any provision of this Agreement shall be valid unless such waiver is in writing and signed by each of the parties hereto.

Severability*

I agree to the following:

If any provision of this Agreement is held invalid by operation of law or by a Court or other tribunal of competent jurisdiction, such provision shall be inoperative, but all other provisions shall not be affected thereby and shall continue in full force and effect.

Name of Participant*

Name of Parent / Legal Guardian*

Parent / Legal Guardian Signature*

Use your mouse, stylus, or finger to sign in the box below. To erase, click the circle in the corner below the box.

Date*