WASHINGTON YOUTH ACADEMY CERTIFICATE OF UNDERSTANDING AND RELEASE OF LIABILITY I, Parent/Guardian of have applied for enrollment into Washington Youth Academy (WYA) and do hereby certify that: 1. I hereby permit my youth to participate in all program activities which may include program approved adventure training/unique activities such as rappelling, ropes course, rock climbing, military aircraft and/or vehicles rides, tough physical training, and sports as well as various off- campus activities such as community service work and job shadow during and for a period of 12 months following the residential phase of the program. 2. I authorize the WYA to conduct background checks that may be deemed appropriate. I fully understand that the information obtained may be sensitive, confidential and privileged in nature and may affect my selection, participation and/or dismissal. (Note: The WYA adheres to proper handling and storage of personal identifying information, medical, and other personal records. 3. My youth will be residing at WYA in Bremerton, WA for the 22 week residential phase unless released or on an authorized pass. 4. WYA has my permission to release photographs/biographies of my youth to the media for marketing materials and non-confidential information of me to the same for publicity purposes. I also understand that this non-confidential information may be released by WYA to any Youth Challenge approved source without my further consent, for example national, state, local officials, news, radio and print media or for use in WYA’s information/marketing materials. 5. I fully understand the WYA has a highly disciplined quasi-military environment and I understand that with my student’s compliance the program will provide an opportunity for my youth to make significant positive change. 6. I give my permission for WYA staff to maintain discipline in the program by imposing program approved disciplinary measures upon my youth for example intense physical training, such as pushups, leg raises etc. Other measures may include loss of privileges up to and including dismissal. 7. During the course of the program, my student agrees to be randomly tested for drugs and alcohol. I understand that a positive test for illegal substances, drugs not prescribed by a medical professional, or alcohol will result in my youth’s immediate dismissal from the program. (This is not a waver able offense). 8. I give my permission for the designated mentor to have communication and contact with my student. I allow the designated mentor to transport my son/daughter on visitation days and post-residential meetings. 9. I understand the WYA collects/maintains Personally Identifiable Information (PII) and information maybe released in accordance with FERPA guidelines as appropriate necessary to complete the WYA mission. 10. I confirm that I have been accurate and complete in all the information I provided to the WYA through the application process. _______ My signature below authorizes the WYA to collect, maintain, and release PII as previously outlined. FURTHERMORE, in consideration of my voluntary participation in the Washington Youth Academy, I HEREBY RELEASE all agencies and partners who participate in and support training activities at the WYA which may include but is not limited to Naval Base Kitsap, Joint Base Lewis-McChord, Washington Military Dept., The United States Government, and the State of Washington, or other military facilities/sites, the officers, agents, employees, and successors assigned from any and all liability which may arise from my application, selection, participation or dismissal from WYA and I AGREE to indemnify and hold harmless the U.S. Government, the State of Washington, the Washington National Guard, the Washington Youth Academy, the officers, agents employees, successors and assigns regarding any liability of cause of action which may arise from my participation in this program. IN WITNESS WHEREOF, I have affixed my signature hereto this ___ day of ______________, in the year ______. SIGNATURE Parent/Guardian/Self (if 18 years old) STATE OF WASHINGTON COUNTY OF The foregoing instrument was acknowledged before me this day of ____ by ___ Comm. Exp Notary Signature STATE OF WASHINGTON MILITARY DEPARTMENT Camp Murray • Tacoma, Washington 98430-5000 WASHINGTON YOUTH ACADEMY HOLD HARMLESS AGREEMENT In consideration of the privilege of access to and use of Camp Murray, the Naval Base Kitsap, Joint Base Lewis McChord, the Yakima Training Center, or other military reservation/site (to include transportation in Government owned, operated, or contracted vehicles, vessel or aircraft of any type) for the purpose of training on the confidence course, obstacle course or similar training range/site/facility ___________________________________, I, being over the age of 18 years, or being the parent or guardian of _________________________________, do hereby covenant and agree, on my own/their behalf and on behalf of my family, heirs, assigns, executors and administrators, that I/my student will never institute, prosecute, or in any way aid in the institution of prosecution of any claim, demand, action, or cause of action for damages, costs, loss of service, expenses or compensation for any damage, loss, or injury either to person or property, or both, arising out of the above-described activity, against the Washington National Guard, the United States Government, the United States Army, The United States Air Force, or any of their instrumentalities. I certify that I/my student am/is in good health and suitable physical condition to participate in the above-described activity, and that I understand the nature of the activity and the risks and hazards involved. I/my student voluntarily assume them. I certify that I have read the above, I understand it, and my signature confirms full acceptance. _______________________________ ______________ _____________________________ SIGNATURE DATE SIGNATURE (WITNESS) .