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B-RELYT Programs
Which B-RELYT program are you registering for?

Section I: Student Information

What would you like to learn more about?

Section II: Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian 2

Section III: Emergency Contact Information

*must be someone different than parent/guardian named above

Section IV: Health Insurance Information

Section V: Parental Consent for Photography and Participation in Evaluation Studies

Please indicate if you give permission for your child to participate in the following activities:

Photography*

*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote B-RELYT's mission and the mission of the LA Stem Collective.

Media/Photo Release*

Media Release of Information*

*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote B-RELYT's mission and the mission of the LA Stem Collective.

I have read the RELEASE AND WAIVER OF LIABILITY FOR ALL AFTER SCHOOL CLASSES AND PROGRAMS.

PARTICIPANT

In signing this Acknowledgement of Risk and Waiver of Liability I hereby acknowledge and represent that I am of legal age and have read this document in its entirety, understand it, and sign it voluntarily.

PARENT/GAURDIAN 1

Participants who are under 18 years of age, or not legally competent, must sign above, and also must obtain the signature of a parent or legal guardian below: I certify that I am the parent or legal guardian of the above-named participant. On behalf of myself and my spouse, partner, co-guardian or any other person who may represent the participant, I have read the above agreement, I understand its contents, assent to its terms and conditions, and sign it of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent’s participation, and I hereby give my consent to participation by my dependent, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend B-RELYT and all B-RELYT Staff Members from and against all claims, demands or suits that my dependent has or may have.

PARENT/GAURDIAN 2

Participants who are under 18 years of age, or not legally competent, must sign above, and also must obtain the signature of a parent or legal guardian below: I certify that I am the parent or legal guardian of the above-named participant. On behalf of myself and my spouse, partner, co-guardian or any other person who may represent the participant, I have read the above agreement, I understand its contents, assent to its terms and conditions, and sign it of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent’s participation, and I hereby give my consent to participation by my dependent, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend B-RELYT and all B-RELYT Staff Members from and against all claims, demands or suits that my dependent has or may have.

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