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Consent for Participation
I authorize Better Wiser Stronger (BWS) Program to provide programming to my son:
*
Indicates required field
Youth name
*
Better Wiser Stronger, Inc. (BWS) provides methods to alter the life outcomes of young urban males. Our goal is to provide young men with opportunities to succeed. This approach is applied through mentoring, workshops/seminars and hands on experiential learning.
I understand that my participation and that of my child in this program is voluntary. I will receive a schedule detailing the location, time, and dates of all respective meetings.
I give permission for my child to attend scheduled field trips. I give permission for my child to be transported by authorized Better Wiser Stronger executive director, staff and volunteers.
I give permission for my child and myself to be photographed, interviewed, and/or televised for use in public relations communications through newspapers, magazines, books, movies, videotape, internet websites, or educational media.
I give permission for my child to participate in assessments, surveys and focus groups for the purpose of receiving feedback regarding Better Wiser Stronger Program.
Submit
Student Information
*
Indicates required field
Full Name: (First / Middle Initial / Last)
*
Date of Birth
*
Age
*
Race
*
American Indian or Alaskan Native
Hispanic or Latino
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to respond
Other
Please specify if Other
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
School
*
Grade
*
Youth Cell Phone
*
Youth Email
*
Parent/Guardian Name
*
Relation
*
Home Phone
*
Cell Phone
*
Parent Email
*
Submit
Emergency Contact Information
*
Indicates required field
I (parent name),
*
grants permission to Better Wiser Stronger organization to seek emergency treatment for my son:
(Participant’s name)
*
if necessary and I agree to accept financial responsibility for the costs related to this emergency treatment. In the event a Better Wiser Stronger staff member or volunteer cannot reach me, please contact the following Emergency Contact Person I have designated.
Emergency Contact Name
*
First
Last
Home Phone
*
Cell Phone
*
Medical Information
Preferred local hospital
*
Physician’s Name
*
Phone
*
Youth’s Allergies
*
Insurance Information (if available)
Company
*
Policy #
*
Comments (include any special medical or personal information you would want an emergency care provider to know – or special contact information.
*
Submit
Waiver of Liability, Assumption of Risk & Indemnity Agreement
*
Indicates required field
Participant's Name
*
First
Last
Waiver:
In consideration of being permitted to participate in any way in hereinafter called Better Wiser Stronger activities, I, for myself, my heirs, personal representative or assigns,
do herby release, waive, discharge, and covenant not to sue
Better Wiser Stronger, its officers, employees, and agents from liability from any and all claims
including the negligence of Better Wiser Stronger, its officers, employees, volunteers and agents
, resulting in personal injury, accidents or illnesses (including death) and property loss arising from, but not limited to, participation in Better Wiser Stronger program.
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the program. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
Indemnification and Hold Harmless:
I also agree to INDEMNIFY AND HOLD Better Wiser Stronger HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in the program and to reimburse them for any such expenses incurred.
Severability:
The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Michigan and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding
: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand
that I am giving up substantial rights, including my right to sue.
I acknowledge that I am signing the agreement freely and voluntarily,
and intend by my signature to be a complete and unconditional release of all liability
to the greatest extent allowed by law.
Submit
Home
BWS Store
About
About Us
Staff & Volunteers
Our Sponsors
Our Programs
Success Stories
Events/Calendars
BWS Media
BWS Video
Teach Me 2 Tie II
Photo Gallery
Get Involved/Help Us
Become A Mentor
Donate
>
Bigger and Better Fundraiser 2021
Volunteer
Student Sign Up
Intake Form
Contact
Support Us