Student Registration Form
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Email *
First and Last Name of Student *
Which school do you attend? *
What grade are you in (2021-2022 school year)?
Which pronouns best describe you? *
How do you describe your race and/or ethnicity? *
What is your home address? *
What is your email address? (if different from above)
What is your t-shirt size? *
Do you have any allergies, dietary restrictions, or medical conditions that we should be aware of? *
Student Conduct Agreement
1. Students are expected to abide by the nightly curfew set by their school and/or chaperone(s).

2. The use of alcohol, tobacco, drugs, vaping, and any other illegal substances is strictly prohibited.

3. Students should anticipate their medical needs and carry medication, inhalers, sanitary needs, etc. at all times since students will not be able to leave the Tearing Down the Walls area (Ensworth School) to retrieve or purchase these items.

4. Students must attend all required conference sessions, meals, and activities.

5. During all conference sessions, conference faculty must be informed of the whereabouts of each student participant at all times. Students are to report to the conference for check-in with the chaperones; chaperones are also responsible for students upon dismissal.

6. Students must refrain from the use of profane language.

7. If a student is dismissed from this conference, the student's parents are responsible for any additional travel expenses. The student's school is responsible for determining if any follow-up disciplinary action is necessary.

8. Students are allowed to have cell phones at the conference, but they are expected to use such devices professionally and in accordance with best practices in listening to and participating in all workshop sessions.

By electronically signing below, you agree to follow these conference rules and understand that violating any of them could result in your dismissal from the conference.
Student Signature -- acknowledgment of conduct expectations *
Parent/Guardian Signature -- acknowledgment of conduct expectations *
Parents' Authorization and Indemnification Agreement
For each Tearing Down the Walls participant, a Student Conduct Agreement with all required signatures and a signed Parents' Authorization and Indemnification Agreement (Medical Release Form) must be uploaded at the time of registration. Without these forms, the registration process will not be completed, and students will not be allowed to participate in the Tearing Down the Walls conference. School chaperones or administrators should bring a copy of students' forms with them or have a way to access to these forms.

I. PARENTAL PERMISSION TO PARTICIPATE
As a custodial parent/guardian of the named participant, I have given him/her my permission to participate in the 2022 Tearing Down the Walls conference. Before signing this permission form, I had the opportunity to satisfy myself as to the adequacy and safety of the arrangements for the Tearing Down the Walls conference. I am familiar with the mental and physical health of my child/ward and his/her ability to travel to unfamiliar places and be exposed to people of different ethnic, cultural, and linguistic backgrounds. My permission for my child to participate is based upon my belief that s/he has the maturity and self-confidence to be able to respond appropriately to the challenges which s/he will encounter during the Tearing Down the Walls conference, as they have been described in the printed materials which I have been given.
II. PARENTAL RISK SHARING AND INDEMNIFICATION AGREEMENT
I recognize that there are risks to my child's person and property involved in air travel, in surface transport, and in staying in a college dormitory. I also understand that Tearing Down the Walls could not afford to offer the 2022 Tearing Down the Walls conference if it was required to bear the sole financial responsibility for those risks. I agree to share the risk of loss arising from injury to my child/ward and/or his/her property with Tearing Down the Walls by entering into this indemnification agreement, in which I accept responsibility for all losses, except those caused exclusively by the negligence of Tearing Down the Walls and/or its agents.

I have reviewed the plans for the Tearing Down the Walls conference and recognize that use of regularly scheduled airlines or other vehicles to provide transportation between our home and Nashville involves risks to person and property, which may include serious injury and death, and I agree to accept those risks. From my review of the plans for the 2022 Tearing Down the Walls conference, I am aware that my child/ward will also be exposed to the risks of surface travel in cars, taxis, and buses while participating in conference activities, including volunteer activities, and I accept the responsibility for those risks. I have reviewed the arrangements for the Tearing Down the Walls conference, and understand that my child may be staying in a hotel with other students and their chaperones; and I accept the risk that injury may occur to my child while staying in Nashville.

On the basis of my review of the plans for the 2022 Tearing Down the Walls conference, and to induce Tearing Down the Walls to allow my child/ward to participate in the Tearing Down the Walls conference, I, in my capacity as parent/ward of the named participant, and for myself and my heirs, successors and assigns, agree to indemnify Tearing Down the Walls and its trustees, officers, employees, and agents (the "Indemnities") for any sums of money for which the Indemnities may become liable as a result of any claim, suit or cause of action which I or my heirs, legal representatives, successors and assigns my child/ward may have, now or in the future, arising out of my child/ward's participation in the Tearing Down the Walls 2022 conference, unless the claim, suit or cause of action arises solely and exclusively from the negligence​ ​of​ ​the​ ​indemnities,​ ​which​ ​I​ ​have​ ​not​ ​waived​ ​or released​ ​by​ ​signing​ ​this​ ​form.
III. COVID-19 WAIVER
ASSUMPTION OF THE RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19:

I voluntarily agree to assume all of the forgoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)'s participation.

On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless Give and Go, its employees, representatives, and Board, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Give and Go, its employees, representatives, and Board, whether a COVID-19 infection occurs before, during, or after participation in our program.  
Name of Student Participant
Electronic Signature of Parent/Guardian
Date of Signature
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IV. MEDICAL TREATMENT AUTHORIZATION
As the parent/guardian of the student participant in the Tearing Down the Walls 2022 conference, I authorize physicians and/or other medical personnel, at the direction of Tearing Down the Walls or my child's chaperone, to provide medical care to my child/ward while s/he is away from home and participating in the Tearing Down the Walls 2022 conference, including examining, treating, and prescribing medications for his/her care.

I understand that Tearing Down the Walls and/or the chaperone will, to the greatest extent possible, consult with me concerning the reasons for and effects of all such care. Recognizing that it may be impossible to reach in situations in which the physicians treating my child/ward believe that beginning treatment is medically necessary, I authorize Tearing Down the Walls or the chaperone to permit commencement of treatment when, in the professional judgement of the physicians or medical personnel involved, such treatment is medically necessary, even if I/we have not yet been consulted. In authorizing such emergency treatment, I agree to accept the determination of the treating physician or surgeon that the treatment or examination rendered was medically necessary to protect the life, health or mental well-being of my child/ward. I give this authorization on the condition that the treating physician will attempt to contact me, if at all possible, before the treatment or examination is rendered.
Name of Student Participant *
Electronic Signature of Parent/Guardian *
Date of Signature *
MM
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DD
/
YYYY
V. INSURANCE INFORMATION
My child/ward is entitled to medical insurance benefits under the following policy:
Name of Medical Insurer *
Medical Policy ID Number *
Medical Policy Group Number *
Medical Policy Group Number *
VI. IN CASE OF EMERGENCY, I CAN BE REACHED AT THE FOLLOWING TELEPHONE NUMBERS:
Emergency Contact #1: Name, Relationship to Student, and Phone Number *
Emergency Contact #2: Name, Relationship to Student, and Phone Number *
VII. PHOTO RELEASE
I hereby grant Tearing Down the Walls permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.I understand and agree that all photos will become the property of Tearing Down the Walls and will not be returned.I authorize Tearing Down the Walls to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising from or related to the use of the photo.

I HAVE READ, AND I UNDERSTAND AND ACCEPT, THE ABOVE PHOTO RELEASE.
Electronic Signature of Student *
Electronic Signature of Parent/Guardian *
A copy of your responses will be emailed to the address you provided.
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