Youth Mentoring Program Waiver

YOUTH MENTORING PROGRAM WAIVER

Program and Participant Information

Participant Name:    Date of Birth:

Parent / Guardian Information (if participant is a minor)

Emergency and Medical Information

Program Schedule and Logistics

Program Start Date:    Expected End Date:

Waiver, Release, and Assumption of Risk

I, the undersigned, on behalf of the participant named above and, where applicable, on behalf of myself, my heirs, executors, administrators, and assigns, hereby acknowledge and agree as follows:

1. Acknowledgement of Risk: I understand that participation in mentoring activities, events, transportation, and related programs may involve known and unknown risks, including but not limited to physical injury, illness, emotional injury, property loss, or death. I voluntarily assume all risks associated with participation.

2. Release and Waiver: To the fullest extent permitted by law, I release, waive, discharge, and covenant not to sue the Youth Mentoring Program, its administrators, directors, officers, employees, volunteers, mentors, contractors, agents, sponsors, and affiliates (collectively Program Parties) from any and all liability, claims, demands, actions, or causes of action arising out of or relating to any loss, damage, injury, or death that may be sustained by the participant, whether caused by the negligence of the Program Parties or otherwise, arising from participation in program activities.

3. Indemnification: I agree to indemnify and hold harmless the Program Parties from any and all claims, actions, suits, damages, liabilities, costs and expenses (including reasonable attorneys' fees and costs) arising out of or resulting from participation by the participant, including claims brought by third parties.

4. Consent to Transportation and Medical Treatment: In the event of an emergency, I authorize program staff or designated volunteers to obtain emergency medical treatment for the participant and to transport the participant to a medical facility. I consent to necessary medical treatment and agree to be responsible for any costs incurred. I understand program staff will make reasonable efforts to contact the emergency contacts listed above.

5. Compliance with Rules: I agree that the participant will comply with all program rules, directions of program staff and mentors, and applicable codes of conduct. I understand that failure to comply may result in temporary or permanent removal from the program without refund of fees, if any.

6. Mandatory Reporting: I acknowledge that program staff and volunteers are mandated reporters with a legal obligation to report any suspected abuse or neglect of a minor to appropriate authorities.

7. Severability and Governing Law: If any provision of this waiver is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. This waiver shall be governed by the laws of the jurisdiction in which the program operates, without regard to conflict of laws principles.

Authorizations and Consents

Media Release: I consent to permit the Program Parties to photograph, record, and use likenesses, images, and recordings of the participant for promotional, educational, or archival purposes in any medium. I understand that such materials may be edited, copied, distributed, and displayed without compensation to me.

Privacy, Data, and Background Screening

I understand that personal information provided on this form will be used for program administration, safety, and communication. I further acknowledge that the program may perform background checks or screenings of mentors and volunteers consistent with program policies to protect participant safety.

Additional Notes / Special Instructions

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