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PARENT PERMISSION AND PICTURE RELEASE

Do Something Anti-Bullying Foundation

I give my child permission to participate in the DSABF Student Ambassador Program


____________________________ _________
______________
____________
Students Name
Grade
School Attending
D/O/B
_________________________________ ________________________
Parent/Guardians Name (Please print)
Signature

___________
Todays Date

__________________________________ ________________________
Home Address
City
Zip
_____________________
Home Phone

_____________________________
E-mail

__________________
Cell Phone

Student Shirt Size (Adult Sizes) SMALL MEDIUM LARGE X-LARGE XX-LARGE XXX-Large (Circle One)
My child will attend (Please check the trainings/meetings your child will attend)
Training 1 _______ Training 2 _______Training 3 _______ Training 4 _______
February
March
April
May
I, _________________________, the parent of ___________________________ understand that my
child must have completed a total of 8 hours of the ambassador course to be inducted into the
Student Ambassadors. I will make arrangements with DSABF for a make up if a training/meeting
is missed.
_____________________________________ _____________________________________
Parent/ Guardian Signature
Student Signature

EMERGENCY CONTACT INFORMATION


In case of emergency please contact:
________________________
Name

_______________________
Relationship

_____________________
List any Allergies

____________________

________________
Phone

*In case of an emergency involving my child, I give permission for the DO SOMETHING ANTIBULLYING FOUNDATIONS staff to seek emergency medical treatment for my child and to act as
guardian in permitting medical treatment if unable to reach me.
I understand that all emergency and/or medical costs are my responsibility.
___________________
Parent/Guardian Name

_________________________
Signature

________________
Date

RELEASE OF LIABILITY
*I understand the organization of Do Something Anti-Bullying Foundation assumes no
responsibility or liability for injuries/illnesses of my child. I further understand that I hold
the organization of Do Something Anti-Bullying Foundation assumes, its officers, agents,
employees, and volunteers harmless from any and all liability or claims, which may arise out of
my childs participation in the Student Ambassador Program
Signature of Parent/Guardian ______________________________ Date ______________
STUDENT RELEASE PICK UP POLICY
As parent/guardian, I understand that the Student Ambassador Program will begin promptly at the
times scheduled and notified to the parents and will end in exactly two hours. In order to be
released to go home from the program, students under the age of 18 can and will only be
released to a parent, guardian or older sibling with parents consent. The individuals picking up
must have a state Drivers License/ ID number on file.
________________________
Parent/Guardian Signature

_____________________
Date

When I am unable to pick my child up, I give permission to the following people to pick up my child
_____________________________
_______________________ _______________
Name/Relationship
Phone Number
D/L #
_____________________________
_______________________ _______________
Name/Relationship
Phone Number
D/L #
_____________________________
_______________________ _______________
Name/Relationship
Phone Number
D/L #
*REMEMBER: Please pick up your child on time. The program ends promptly two hours from the
start time. If students are not picked within 15 minutes of the trainings end time, DSABF
Administrators will then begin contacting those on the consent to release list.
Please note: Excessive tardiness in picking up your child may result in his/her dismissal from the
program.
PHOTO/VIDEOTAPING RELEASE
During your childs attendance in the Student Ambassador Program, he/she may be
participating in an activity that is being photographed or videotaped; these
My child
photographs/video recordings may be used for promotional purposes.
___may
___may not be
photographed/videotaped by the program for promotional purposes.
*As parent/guardian, I understand that I hold Do Something Anti-Bullying Foundation, its officers,
agents, and employees harmless from any and all liability or claims which may arise out of or in
connection with my childs being photographed or videotaped while participating in the DSABF Student
Ambassador Program

____________________________
Parent/Guardian Signature

_____________________
Date