Consent, Indemnity and Release of Liability

CONSENT, INDEMNITY AND RELEASE OF LIABILITY

Please print this CONSENT, INDEMNITY AND RELEASE OF LIABILITY form and sign. No girl can participate in the Project without a signed CONSENT, INDEMNITY AND RELEASE OF LIABILITY.

The Positively More project (the “Project”) is a project developed and sponsored by The Junior League of

Greenwich, Connecticut, Inc. (the “Organizer”). The Project is focused on 11 and 12 year-old girls and aims to give girls the tools to avoid questionable situations, lessen the consequences of potential conflicts, and identify lessons learned by those challenges. The Project will include a variety of topics stemming from the core themes of (1) identifying and listening to your moral compass, (2) the value of friendships, (3) middle school 101, and (4) practice using your moral compass. The topics will be presented in different teaching styles (including lecture style presentations, round table discussions and question/answer formats). Specifically, the Project is designed to inform the participants of the consequences of poor choices, and identify alternate ways to deal with challenging situations. The Project discusses the concept of their bodies and impactful choices. The Project examines effects of choices made on friendships both inside and outside of school. The project acknowledges middle school girls today as digital citizens. Additionally, Positively

More allows the pre-teen to practice in role-playing activities the tools that were taught to them during the day. The

Project is divided into the following workshops:

• Valuing Yourself

• The Value of Friendships

• Middle School 101

• Practice Using Your Moral Compass

As parent/guardian of ______(child’s name) (“Participant”), I agree as follows:

Content: I acknowledge that I have read this Consent (including the project content listed on the website at www.jlgreenwich.org) and the Registration Form and that I understand and accept that participation in this project may give rise to topics of discussion not specifically set forth herein and/or result in the occurrence of unforeseen circumstances resulting from accidents, exposure to sickness and/or loss of personal property and/or damage thereto. As parent/guardian of the Participant, I accept all risk of any unforeseen circumstances arising from this project (including personal injury, disease, emotional distress, discussion topics and/or damage to Participant, property or to third parties). Illness or Accident: In case of illness or accident, please contact me at the emergency phone number set forth on the Registration Form. In such event, I hereby grant the Organizer permission to facilitate and/or to administer emergency medical care to the Participant. It is further understood that the undersigned will assume full responsibility for any such action, including payment of all costs.

Confidentiality: As a general rule, the Organizer (including its shareholders, members, directors, officers, employees, volunteers, agents and program staff/instructors) (collectively, the “Releasee”) will keep information shared during this project confidential. In some situations, the Releasee is required by law or by the guidelines of its profession to disclose information without permission. Confidentiality cannot be maintained when:

1. A participating child in the project states she plans to cause serious harm/death to herself, and the Releasee believes the child has the intent/ability to carry out this threat in the very near future.

2. A participating child in the project states she plans to cause serious harm/death to someone else who can be identified, and the Releasee believes the child has the intent/ability to carry out this threat. The Releasee must then inform the Guardian and the person identified to harm.

3. A participating child in the project states she is being abused – physically, sexually or emotionally – or that the child has been abused in the past. The Releasee is required by law to report the abuse to the Connecticut Department of Children and Families. Release of Liability/Indemnity: AS PARENT/GUARDIAN OF THE PARTICIPANT, I, FOR MYSELF, THE PARTICIPANT, MY (OUR) HEIRS, EXECUTORS, LEGAL GUARDIANS AND ADMINISTRATORS (COLLECTIVELY, THE “RELEASOR”), TO THE EXTENT PERMITTED BY LAW, HEREBY REMISE, RELEASE, WAIVE AND FOREVER DISCHARGE THE RELEASEE FROM AND AGAINST ANY AND ALL LIABILITIES, LOSSES, DAMAGES, CLAIMS, ACTIONS, CAUSES OF ACTION, DEMANDS OR COSTS OF ANY NATURE WHATSOEVER, INCLUDING ORDINARY NEGLIGENCE, THAT MAY ARISE IN CONNECTION WITH THE PARTICIPANT’S PARTICIPATION IN THIS PROJECT, THE ORANIZER’S ACTION(S) AND/OR ANY RELATED ACTIVITIES. TO THE EXTENT PERMITTED BY LAW, I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEE FROM AND AGAINST ANY AND ALL COST, EXPENSE, FEES (INCLUDING LEGAL FEES), LIABILITY (ARISING FROM INJURY OR OTHERWISE), LOSS, DAMAGE, CLAIM, DEMAND, SUIT, ACTION OR CAUSE OF ACTION, OF ANY NATURE WHATSOEVER, ARISING FROM OR IN CONNECTION WITH PARTICIPANT’S PARTICIPATION IN THIS PROGRAM AND ANY RELATED ACTIVITIES (INCLUDING UNFORESEEN CIRCUMSTANCES, DISCUSSION TOPICS, AND/OR SERVICES PROVIDED BY THIRD PARTY CONTRACTORS AND/OR INVITEES WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEE OR CAUSED BY OTHER MEANS. THE TERMS OF THIS DOCUMENT SHALL BE BINDING ON MY HEIRS AND PERSONAL REPRESENTATIVES.

Jurisdiction: This Consent shall be interpreted, construed and enforced in accordance with the laws of the State of Connecticut. If any legal action arises out of or is in any way connected with my child’s participation in this project, I consent to the exclusive jurisdiction of any State or Federal Court located in the State of Connecticut having subject matter jurisdiction and waive any objection to such venue or convenience of such forum.

In case any one or more of the provisions contained in this Consent shall for any reason be held to be invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and this Consent shall be construed as if such invalid, illegal or unenforceable provision had never been contained herein.

I HAVE READ THIS CONSENT (INCLUDING THE PROJECT CONTENT). I FULLY UNDERSTAND THE TERMS AND THEIR LEGAL EFFECT, AND I HEREBY SIGN IT FREELY AND VOLUNTARILY. I FURTHER STATE THAT I AM THE PARENT/LEGAL GUARDIAN OF THE CHILD NAMED HEREIN, THAT I AM AUTHORIZED AND COMPETENT TO SIGN THIS CONSENT, AND THAT I CONSET TO MY CHILD’S PARTICIPATION IN THIS PROJECT IN CONSIDERATION OF THE TERMS SET FORTH HEREIN.

Photography Do you give permission for photographs to be taken of the child Participant to be used for marketing materials?

___ Yes ___ No

______Parent/Guardian Signature

______Parent/Guardian Name (PRINTED)

Relationship to Participant: ______Date: ______Child’s Name (“Participant”): ______