RELEASE and WAIVER of LIABILITY FOR MINORS (ages < 18 years)
This release and Waiver of Liability (the “Release”) executed on this ______ day of_____________, 2018, by ______________________________________________(parent/ guardian / caregiver) in favor of ImPACT PEOPLE AGAINST CHILD TRAFFICKING IN AMERICAN SCHOOLS, a nonprofit 501(c)(3) organized and existing under the laws of the Commonwealth of Virginia, USA, and their directors, officers, volunteers, and agents (collectively, “ImPACT People Against Child Trafficking in American Schools”).
The Minor________________________________________________desires to attend the YOUTH SAFETY SUMMIT and the EMPOWER YOUTH PREVENTION WORKSHOP and engage in the activities voluntarily, without duress, execute this Release under the following items:
Waiver and Release: The parent / guardian / caregiver and minor release and forever discharges and hold harmless ImPACT People Against Child Trafficking in American Schools and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from the minor’s participation in the Youth Safety Summit and the Empower Youth Prevention Workshop. The parent/ guardian / caregiver understands and acknowledges that this Release discharges ImPACT People Against Child Trafficking in American Schools from any liability or claim that guardian and minor may have against ImPACT People Against Child Trafficking in American Schools worksite. It is also understood that ImPACT People Against Child Trafficking in American Schools does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance in the event of injury, illness, death or property damage.
Insurance: The parent / guardian / caregiver understands that we expressively waive any such claim for compensation or liability on the part of ImPACT People Against Child Trafficking in American Schools beyond what may be offered freely by the representative of ImPACT People Against Child Trafficking in American Schools in the event of such injury or medical expense. Medical Treatment: The parent / guardian / caregiver and minor hereby release and forever discharge ImPACT People Against Child Trafficking in American Schools from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during the minors time with ImPACT People Against Child Trafficking in American Schools.
Assumption of Risk: The parent / guardian / caregiver understands that the minors time with ImPACT People Against Child Trafficking in American Schools may include topics related to nature and scope of child / teen human trafficking, both labor and sex trafficking; the red flags of child / teen human trafficking, both labor and sex trafficking; survivor stories of both labor and sex trafficking; and protocols for response to exploitation that would ensure the safety and wellbeing of the child / teen from exploiters, including human traffickers. As the parent / guardian / caregiver for the said minor I hereby expressly assume the risk of injury or harm in these educational activities and release ImPACT People Against Child Trafficking in American Schools from all liability for injury, illness, death or property damage resulting from the activities of the minors time at the Youth Safety Summit on Human Trafficking.
Photographic Release: As the parent / guardian / caregiver of said minor I grant and convey unto ImPACT People Against Child Trafficking in American Schools all right, title, and interest in all photographic images and video or audio recordings made by ImPACT People Against Child Trafficking in American Schools during the minor’s participation with ImPACT People Against Child Trafficking in American Schools.
Other: As the parent / guardian / caregiver of said minor, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Virginia in the United States of America, and that this Release shall be governed by and interpreted in accordance with the laws of the Commonwealth of Virginia. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall no otherwise affect the remaining provisions of this Release, which shall continue to be enforceable.
To express my understanding of this Release, I sign here.
Name of Parent / Guardian / Caregiver:
___________________________________________________________
Name of Dependent / Minor:
___________________________________________________________
Address of Parent / Guardian / Caregiver:
___________________________________________________________
Phone: ___________________________________________________
Emergency Contact (if different from above)
Name:_____________________________________________________
Phone: ___________________________________________________
SIGNATURE:
__________________________________________DATE:____________
Please return this Release Form to
Fay Chelmow at fay.chelmow@ImPACTvirginia.org
or mail to P.O. Box 63, Midlothian, VA 23113
