PARENT/GUARDIAN CONSENT FORM

I, the undersigned have legal custody of the participant named below, a minor, and
have given my consent for _____________________________________to
participate in the 2014 Blueprint Conference for iddle ! "igh #chool $irls at
#immons College hosted by the %ational &lumnae &ssociation of #pelman College,
Boston &rea Chapter' I give my permission for the participant to engage in all
activities'
In case of a medical emergency, I understand that every effort will be made to
contact me or the emergency contact listed below' In the event that someone cannot
be reached, I hereby authori(e and consent to any )*ray, e)amination, anesthetic,
surgical diagnosis, medical treatment and+or hospital care which is deemed advisable
by, and rendered under the general or special supervision of any licensed medical
personnel on the staff of any licensed hospital'
Emergency Contact Details:
%ame,

-elation to .articipant,

"ome .hone %umber,

obile .hone %umber,
Health Concerns:
/oes your child have any food allergies0 1es %o
If yes, please e)plain,

/oes your child have any dietary restrictions0 1es %o
If yes, please e)plain,
Can your child participate in physical activities 2i'e' beginners+basic 3umba, Cardio40
1es %o
If no, please e)plain,

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y child is a participant in the 2014 Blueprint Conference at #immons College
sponsored by %&&#C Boston &rea Chapter 25the 6rgani(ation74, and I am fully aware
of the ris8s and ha(ards connected with her participation in 25&ctivity74, and hereby
elect to voluntarily have her participate in the &ctivity, 8nowing that the &ctivity may
be ha(ardous to her or her property' I 96:;%<&-I:1 &##;= &::
-=#.6%#IBI:I<1 >6- &%1 -I#?# 6> :6##, .-6.=-<1 /&&$=, 6-
.=-#6%&: I%@;-1, that may be sustained by her, or any loss or damage to
property owned by her, as a result of being engaged in the &ctivity, A"=<"=-
C&;#=/ B1 <"= %=$:I$=%C= 6> <"= 6-$&%I3&<I6% 6- I<# 96:;%<==-#,
&$=%<#, or otherwise'
I hereby -=:=&#=, A&I9=, /I#C"&-$= &%/ C69=%&%< %6< <6 #;= the
6rgani(ation, the ;niversity, and their officers, agents, employees, or volunteers
2hereinafter 5-=:=&#==#74 from any and all liability, claims, demands, actions, and
causes of action whatsoever arising out of or related to any loss, damage, or inBury,
that may be sustained by or to any property belonging to me, A"=<"=- C&;#=/
B1 <"= %=$:I$=%C= 6> <"= -=:=&#==# or otherwise, while participating in the
&ctivity' It is my e)press intent that this -elease and "old "armless &greement
2hereinafter 5&greement74 shall bind the members of my family, and shall be deemed
as a -=:=&#=, A&I9=-, and /I#C"&-$= &%/ C69=%&%< %6< <6 #;= the
above*named -=:=&#==#' I hereby further agree that this &greement shall be
construed in accordance with the laws of the #tate of assachusetts' I hereby
ac8nowledge that neither the 6rgani(ation nor the sponsored &ctivity is affiliated with
the ;niversity'
Guardian Signature ________________________________ Date_____________
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PHOTO RELEASE FORM
The National Alumnae Association of Spelman College, Boston Area Chapter
(NAASCBAC) is reCuesting your permission to use pictures from the 2014 Blueprint
Conference for iddle ! "igh #chool $irls at "arvard ;niversity that were ta8en of
you+your child' <hese pictures will be used for promotional purposes, and may
appear on websites, brochures, maga(ines, and other media types associated with
%&&#CB&C and+or the Blueprint Conference for iddle ! "igh #chool $irls' &s
such, your+your childDs image will be available in the public domain'
1our signed consent gives NAASC-BAC permission to use pictures of you+your child
on www'naascboston'org, as well as ma8e them available to other third party affiliate
groups'
Sign below if you are in agreement:
I _______________________________________________ agree to allow pictures
of me+my child, ______________________ to be used by NAASC-BAC for purposes
they deem appropriate including, but not limited to those listed above'
#ignature _______________________________
/ate __________________
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