I Believe In Me Inc-Program Waiver (2024)
Upon the completion of this form, I am granting my child permission to participate in the I Believe In Me mentoring program for the 2023-2024 school year and understand the policies and regulations.

 Please make sure to fill out a waiver FOR EACH of your children attending the program.  
We will review and a member of our leadership team will be in contact with you with the next step. Please allow 3-5 business days to review your submission. 
Sign in to Google to save your progress. Learn more
  Parent/Guardian Full Name:
 *
  Parent/Guardian Phone Number:
 *
  Parent/Guardian Email:
 *
Does your child reside with you?
Clear selection
  Parent/Guardian address:
 *
Student Full Name: *
Student's Adress: *
Student's Phone Number: *
Date of Birth: *
MM
/
DD
/
YYYY
Current School Attending: *
  Current Teacher (Elementary) or Counselor (Middle/High) Please include FULL NAME if possible  
 *
Does your child have an IEP, BIP, or 504 plan? 
 *
If yes, to the question above, please select plan:
Clear selection
  What would you like the mentors to know about your child?   
 *
What goals or outcomes would you like to see while your child is a part of the program?   
 *
 Health Insurance Information: (needed only in case of an emergency and parent/guardian can not be reached)  

Do you have health insurance:
 *
If yes, what's the insurance company?
Policy number:
Medical Doctor Contact information: (Name & Phone Number? *
Does your child have any allergies? *
If yes, Please list any allergies your child has, that we need to be aware of. 
If your child suffers of allergies, does your child require an EpiPen?  
Clear selection
Release of Liability:
 By signing this waiver, I expressly warrant that the student named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the student participating in the activities, whether such risks are known or unknown to me at this time. I further release this organization and its leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against this organization or ites leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless this organization and its leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my student during such activities. In addition, I give permission for my student to be transported in an authorized IBM vehicle for/to/from IBM activity locations.
Release to use Image and Likeness 
On occasion, I Believe in Me (IBM) or its representatives takes photographs or makes an audio or videotape recording of the students and/or adults involved in the activities. I consent to the use of any such audio or visual record of the student named above to be used, distributed, or displayed as the agents of the organization see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the student to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media, IBM website and/or social media page(s). In addition, such photographs and audio/visual recordings may be used in publications or advertising materials to let others know about our activities.  
Would you give permission for your child to be photographed and published on our social media platforms?
Clear selection
Transportation Option
Clear selection
Legal representation of minor:
 I represent that I am the parent/guardian of child's name in the above form, who is under 18 years of age. I have read the above Student Permission Waiver and am fully familiar with the contents thereof. I give permission for the student named above to participate in the activities of this organization, including any special events/activities described above. In consideration for allowing the participation of the student in these activities, I hereby consent to the Student Permission Waiver, including the Release of Liability above, on behalf of the student and agree that this Student Permission Waiver shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.   
Please type your full name (Parent or Legal Guardian only) as a form of signature *
I understand, parent involvement is a key component to student growth. I am aware that I am expected to attend parent engagement meetings and communicate with mentors about the needs of my child. (initial)  
 *
Today's Date
MM
/
DD
/
YYYY
Executive Director
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms