Building Bridges - Fall 2024 - Parent Consent Form

Activity: Participation in Northeastern University's Building Bridges Program
Date: Friday, December 6, 2024
Time: 8:45am - 1:30pm

Please note, if you have multiple children participating, this form will need to be completed for each child.

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* 1. Please note, in order to participate in this program you must complete our online registration form (which includes $25 payment per person). The link for the registration form is: https://commerce.cashnet.com/buildingbridges

I have already registered and paid

I have not registered nor paid -> but will do so now

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* 2. Student Information

First Name

Last Name

School

Current Age

Home Address

Home City

Home State

Home ZIP Code

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* 3. Parent/Guardian 1 Information

Parent/Guardian Name (First Last)

Relationship to Student

Email Address

Phone Number

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* 4. Parent/Guardian 2 Information

Parent/Guardian Name (First Last)

Relationship to Student

Email Address

Phone Number

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* 5. Emergency Contact Information

Name (First Last)

Phone Number

Email Address

Relationship to Student

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* 6. Consent to Participate - Part 1 [sign full name in box below]
I, the undersigned (or parent/guardian, if Participant is under the age of 18) understand that this is a legally-binding Release of Northeastern University and the program sponsors.

I/We request permission to participate in the Program described above. In consideration of being granted this permission, and by signing my name (Parent/Guardian) in the field below, I/we agree:

1. Voluntary Activity. I understand and agree that participation in this Activity is purely voluntary and is not required by Northeastern University.

2. Acknowledgment of Risk. I recognize and appreciate the dangers, hazards, and risks of the Activity which could include serious or even mortal injuries and property damage. I attest that I have fully considered the risks and hazards, and I agree that I have individually assumed the risks involved in this Activity.

3. Fitness to Participate. I hereby represent that the participant is physically and mentally able to participate in the above referenced Activity and has no health problems which would present a risk to the participant, or others, in participating in this Activity. I certify the participant has been seen by a healthcare provider within the last year.

4. Compliance with Rules. I understand that the participant is required to abide by the rules of Northeastern University, as well as any rules of conduct promulgated by the sites the participant may visit as a part of participant’s participation in this Activity, and that the rules of conduct promulgated by the sites and facilities will apply in addition to Northeastern University’s rules. I understand that if the participant fails to follow all applicable rules that Northeastern University shall have the right to terminate the participant’s participation privileges immediately and that further actions will be taken if necessary.

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* 7. Consent to Participate - Part 2 [sign full name in box below]
5. Emergency Medical Treatment. I authorize the Released Parties (defined below) to transport the participant to, and to authorize on participant’s behalf emergency medical treatment if necessary, and I understand and agree that such action shall be subject to the terms of this Release. I understand and agree that the Released Parties assume no responsibility for any injury or damage which might arise out of, or in connection with such authorized emergency medical treatment or transport.

6. Insurance. I represent that the participant is covered by adequate health insurance necessary to provide for and pay any medical costs that may be incurred as a result of injury. I guarantee payment of all expenses incurred for transportation of participant to and receipt of emergency medical treatment.

7. Release. I, on behalf of myself, the participant, and our respective family heirs, personal representatives, guardians, successors, and assigns (all of whom are referred to as "Releasors"), hereby release Northeastern University, its Administrators, Faculty, Trustees, Officers, Directors, Employees, Volunteers, and Agents (all of whom are referred to as "Released Parties") from, and agree not to sue the Released Parties for, any claims that I may have arising from, or in connection with, any physical, emotional or mental injury or property damage that Releasors may suffer as a result of the participant’s participation in the Activity from any cause whatsoever, to the fullest extent permitted by law.

8. Permission. In consideration of participation in the Activity, I further hereby agree and grant permission for Northeastern University and/or its designees to record, film, photograph, audiotape, videotape, interview and /or publicly exhibit, display, distribute and/or publish the participant’s likeness, appearance and or spoken words in any form and for any purpose worldwide to perpetuity and without compensation .

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* 8. Release of Legal Rights [sign full name in box below]
THIS IS A RELEASE OF LEGAL RIGHTS, READ BEFORE SIGNING.

I acknowledge that I have carefully read this Release and fully understand its contents. I acknowledge that I am voluntarily executing this Release of my own free will. After having the opportunity to consult with legal counsel of my own choosing, I acknowledge and understand that this Release will release Northeastern University and the Released Parties from all liability in connection with any injury or damages or losses suffered as a result of the participant's participation in the above referenced Activity. It is my express intent that this release shall bind the members of participant's family, estate, heirs

I am the Participant's parent / legal guardian, and am fully competent to sign this Release. I execute this release for full, adequate, and complete consideration, fully intending for myself, the participant, and the participant's family, estate, heirs, administrators, personal representatives, and assigns to be bound hereby.

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* 9. Please make sure you have written your full name for questions 6-8 (consent to participate and release of legal rights) in the boxes below each question. By writing your name in these fields, you are legally signing this digital form.

I have signed my name under each question (6-8), corresponding to the Consent to Participate and Release of Legal Rights forms.

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* 10. Today's Date

Date / Time

Date