CITY SURFERS AFTER SCHOOL APPLICATION: SEPTEMBER 2020 - JUNE 2021
This application is for 2nd - 5th graders at NYC Public Schools 57 and 182 in East Harlem ONLY. We expect the program to operate from September 14th, 2020 - June 18th, 2021. As COVID-19 requirements are set by the government, we will keep you informed about any changes to the expected program dates as well as our activities. Thank you for your patience during this challenging time.
Child's Information
Last Name: *
First Name: *
Address: *
City: *
Zip: *
State/Province: *
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Country: *
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Panama
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Western Sahara*
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Birth Date: *
/ / (mm/dd/yyyy)
Phone: *
Email: *
T-shirt size: *
School: *
Grade: *
Does your child know how to ride a bike? *
Past Concrete Safaris Experience, If any: *
Allergies or Health Conditions, If any: *
Parent/ Guardian Information
Last Name: *
First Name: *
Relationship: *
Address: *
City: *
State: *
Zip: *
Cell Phone: *
Work Phone: *
Emergency Contact
#1
Last Name: *
First Name: *
Relationship *
Cell Phone: *
Work Phone:
#2
Last Name:
First Name:
Relationship
Cell Phone:
Work Phone:
Pick up Information
My child authorized to go home alone? *
Yes
No
If no, Please identify the authorized persons to pick up child from after-school:
Full Name:
Phone Number:
Full Name:
Phone Number:
Organizational Values
I, as parent/guardian, and my child agree to follow Concrete Safaris' Organizational Values during and outside of program hours: Respect, Responsibility, Uniqueness (being our best selves), Listening, Learning, Leadership, Exercising, Eating Healthfully, Positive Energy, Sharing, Safety, Fun, & Friendship.
Parent/ Guardian Full Name: *
E-Signature: Example - John Alex Smith = /JAS/ *
Today's Date:
Media Release
Concrete Safaris or outside media (provided they obtain Concrete Safaris’ permission) may take photographs or videotape participants in Concrete Safaris’ activities. These images may be used for Concrete Safaris’ brochures, newsletters, archives, news releases, publicity and Web sites. I hereby grant permission to Concrete Safaris to take and reproduce photographs and videotapes for publication, including publication by news sources and other sources for all educational, trade, advertising and other purposes as determined by Concrete Safaris.
Parent/ Guardian Full Name: *
E-Sig: Example - John Alex Smith = /JAS/ *
Date Today: *
LIABILITY WAIVER AND RELEASE AGREEMENT
You hereby represent that you are the parent or legal guardian of your child as named in this application (“your child”). This Liability Waiver and Release Agreement {the “Agreement”) sets forth the parties’ understanding and agreement with respect to your child’s participation in the City Surfers after school program hosted by Concrete Safaris (“CS”), which is currently scheduled to begin in September 2020 (the “Program”). Your child’s participation in the Program is contingent on your execution of this Agreement.
WAIVER & RELEASE
In consideration of your child’s ability to participate in the Program, you, on behalf of yourself, your child, and each of your and your child’s respective heirs, executors, administrators, representatives and assigns, hereby agree to release, waive, discharge, covenant not to sue and hold harmless CS, its directors, officers, employees, agents, successors and assigns (hereinafter referred to as the "Releasees") from any and all claims, damages, actions, costs, expenses or losses, whether known or unknown, which now exist or which may exist in the future including without limitation, attorneys’ fees, property damage, personal injury, illness or death, whether caused by negligence, omission or otherwise, in connection with or arising out of your child’s participation in the Program, and you further agree to indemnify and hold harmless the Releasees from and against any and all claims, damages, liabilities arising out of your child’s participation in the Program.
You acknowledge and agree that your child’s participation in the Program involves certain risks to your child and that you are voluntarily permitting your child to participate in the Program with knowledge and understanding of the dangers involved. In particular, you acknowledge that the novel coronavirus, COVID-19, has been declared a worldwide pandemic, is extremely contagious, and that federal, state and local health agencies and governments recommend social distancing and other protective measures to help prevent the spread of the virus. You acknowledge that, even with the use of protective equipment and other safety precautions, your child may be exposed to or contract COVID-19 during the course of your child’s participation in the Program, and you, on behalf of yourself, your child, and each of your and your child’s respective heirs, executors, administrators, representatives and assigns, hereby release, waive, discharge, covenant not to sue and hold harmless the Releasees from any and all claims, damages, actions, costs, expenses or losses arising out of or in connection with any potential exposure to COVID-19 (the release in this paragraph and the foregoing paragraph collectively, the “Release”).
Accordingly, you hereby assume full responsibility for the risk of any bodily injury, illness or death to your child, or property damage to your or your child’s personal property while your child is participating in the Program.
You further expressly agree that the foregoing Release is intended to be as broad and inclusive as is permitted by the law of the State of New York. If any portion thereof is held invalid, it is agreed that such offending provision of the Release shall be severed and the balance shall continue in full legal force and effect.
You understand and confirm that by signing this Release, you have given up considerable legal rights and that you have signed this Release freely, voluntarily, under no duress or threat of duress. You also hereby certify that you are 18 years of age or older and are mentally competent to enter into this Agreement.
You hereby represent that you have read, understand and fully agree to the terms of this Release.
GENERAL TERMS
This Agreement shall be governed by and construed in accordance with the laws of the State of New York, without regard to principles of conflicts of laws.
This Agreement and all rights and obligations hereunder shall be binding upon and shall inure to the benefit of your heirs (including without limitation your child), executors, representatives and administrators and CS’s successors and assigns. You may not assign your or your child’s rights under this Agreement, without the prior written consent of CS.
This Agreement contains the entire understanding between the parties on the subjects covered here and supersedes all prior agreements, arrangements and understandings, whether written or oral, regarding the subjects covered here. You acknowledge that you have not relied on any statements, representations or promises not specifically contained in this Agreement. This Agreement may not be changed or any of its provisions waived orally, but only in writing signed by both parties.
ACCEPTED AND AGREED TO:
Parent/ Guardian Full Name: *
E-Signature: e.g. - John Alex Smith = /JAS/ *
Date: *