CCC Program Participant Waiver - Children's Cancer Connection

Participant(s) Name(s) *

Please type participant(s) first and last name(s). Separate multiple participants’ names by commas.

Program Attending *

Other? Type the program name below.

Other Program:

Date(s) of Program *

Please type in 00/00/0000 format.

Parent/Guardian Name *

First

Last

Parent/Guardian Email Address *

Confirm Email

Consent and Approval *

I agree.

I am the parent/legal guardian of the participant(s) named above, and I hereby give my full consent and approval for my child(ren) to participate in this program at Children’s Cancer Connection, Camp Heart Connection, the Jeff and Deb Hansen Home for Hope or on Children’s Cancer Connection-sponsored field trip/outing. In addition to giving my full consent for my child(ren)’s participation, I do hereby waive, release, and hold harmless Children’s Cancer Connection, its employees, supervisors, volunteers and representatives for any injury that may be suffered by my child(ren) in the normal course of participation in the registered program.

Acceptable Behavior Policy *

I agree.

To ensure a safe and fun environment for all, children are expected to behave in an acceptable manner and use appropriate language at all times. It is important to remember that a child may be asked to leave the program due to unacceptable behavior.

Photo/Video Release *

I agree.

By signing below, I grant permission to Children’s Cancer Connection and its program partner(s) to obtain, store, publish and/or use any photographs, slides, sounds, and/or video recordings made of the program participant(s) named in this form for use on websites, email blasts, social media, advertisements/other promotional pieces, publications, etc. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown.

News Media Release *

I agree.

By signing below, I grant permission to members of the news media authorized by Children’s Cancer Connection and its program partner(s) to obtain, store, publish and/or use any photographs, slides, sounds, and/or video recordings made of the program participant(s) named in this form for use online, on-air, in publications, on social media, etc. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown.

Liability Waiver: *

I agree.

On your own behalf, and as parent or guardian, you acknowledge and agree that there is a possibility of physical injury with your child(ren)’s participation in the program and hereby release, discharge Children’s Cancer Connection, its employees and associated personnel, including the owners of the program facility against any and all claims, liabilities and/or damages as a result of your child(ren)’s participation in the program.

Regarding Events in Which a Participant is Driving: *

I agree.
Not applicable – I do not have a teenager attending this program.

During an event in which a teen participant may drive themselves and/or others, you as the parent/guardian acknowledge that your teen is required to turn in his/her vehicle keys upon arrival and will not be allowed to retrieve them until the program end-time. In the event that the teen needs to leave the facility early, the parent must make prior arrangements with the CCC representative and/or chaperoning adult.

*Notice: For any event that the teen may drive a personal vehicle to, you acknowledge that CCC is not responsible for any accidental claims that may occur while driving to and from the program.

Pick-Up Information *

I agree.

The following people may pick up my child/children from the CCC program. If you are the only authorized person, please provide your own information in the fields below.

*Only those listed below are authorized to pick up the participant(s).*

Name of Person #1 *

First

Last

Phone Number *

Email Address *

Name of Person #2

First

Last

Phone Number

Email Address

Signature *

By typing your first and last name into the signature box above, you are agreeing to all Terms & Conditions listed above.

Today's Date *

Please type in 00/00/0000 format.