DARIEN SAFE RIDES
ACKNOWLEDGEMENT, CONSENT & LIABILITY RELEASE FORM
I ______(parent or guardian’s name), am the parent or guardian of ______(hereafter “child” or “student”), who is applying to participate in the Darien Safe Rides student ______program (the “Program”).
1. I have read the Student Manual and the Safe Rides Application and understand the activities and rules of the Program.
2. I understand that my child will be actively involved in the Program and consent to my child’s participation as a Driver _____, Rider (non-driver) ______, Dispatcher ______(check all that apply).
3. I understand that as a Driver, my child will use my personal vehicle(s) to transport intoxicated or otherwise impaired persons and confirm and acknowledge that my vehicle will at all times be covered by at least $300,000 in automobile liability insurance, in safe operating condition, and legally operational.
4. I know that the nature of the Program and my child’s experience and capabilities, and believe that my child to be qualified to participate in the Program and I know of no medical or other reasons that my child is not capable of participating in the Program.
5. I have considered the risks inherent in the Program, the risks presented to my child’s health and well-being, and his/her interest in furthering volunteer and community services experiences by enrolling in the Program. I have discussed these risks with my child and have concluded that the risks are acceptable and are outweighed by my child’s desire to participate in the Program. I hereby VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY SUCH RISKS.
6. In consideration of Darien Safe Rides permitting my child to participate in the Program, I, to the fullest extent permitted by law, on behalf of myself, my child, my spouse, heirs, representatives, executors, administrators and assigns, AGREE TO AND DO FOREVER RELEASE, WAIVE, AND DISCHARGE DARIEN SAFE RIDES, THE DARIEN DEPOT, THE TOWN OF DARIEN YOUTH COMMISSION, THEIR TRUSTEES, DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, ASSIGNS AND VOLUNTEERS (COLLECTIVELY REFERRED TO AS THE “RELEASED PARTIES”) FROM ANY CAUSE OF ACTION, CLAIMS, OR DEMANDS OF ANY NATURE WHATSOEVER, that I or my child, my spouse, heirs, representatives, executors, administrators and assigns may now have or have in the future against the Released Parties, or any of them, on account of personal injury, bodily injury, property damage, death or accident of any kind, including injuries sustained as a result of the negligence of the Released Parties, or any one of them, arising out of or in any way related to my child’s participation in the Program and its activities on and off the Program’s premises. I also agree to indemnify and hold harmless the Released Parties for any loss, liability, damage or costs, including court costs and attorney’s fees that may occur as a result of my or my child’s negligent or intentional act or omission while participating in the Program.
7. During my child’s participation in the Program, I hereby grant Darien Safe Rides, its employees, agents and volunteers the full authority to take whatever action they may consider necessary or warranted under the circumstances regarding the protection of my child’s health and safety. I hereby release them from any liability, claims, demands, lawsuits or causes of action of any kind or nature whatsoever resulting from any decisions, actions, or omissions.
8. My child will bear the responsibility of complying with all rules, policies, procedures, standards, and instructions related to student behavior and conduct promulgated by the Program or its administrators or volunteers. My child will at all times avoid dangerous or careless activities and follow the rules and regulations of the Program.If my child violates these guidelines, I understand that my child may be subject to disciplinary proceedings and/or expelled from the Program.
9. I acknowledge that Darien Safe Rides has the right to make changes to the Program, its manual, rules and regulations.
10. All references to Darien Safe Rides in this Acknowledgement, Consent & Liability Release Form shall include the officers, directors, staff, volunteers, chaperons, leaders, employees, and agents of Darien Safe Rides, The Darien Depot and the Town of Darien Youth Commission. This Acknowledgement, Consent & Liability Release Form is intended to be as broad and inclusive as is permitted by law. If any provision or any part of anyprovision hereof is held to be invalid or legally unenforceable for any reason, the remainder of thisAcknowledgement, Consent & Liability Release Formshall not be affected thereby and shall remain valid and fully enforceable.
11. This Acknowledgement, Consent & Liability Release shall be construed in accordance with the laws of the State of Connecticut and represents the final and exclusive agreement between Darien Safe Rides, The Darien Depot and the Town of Darien Youth Commission and me and my child.
CONSENT OF PARENT OR LEGAL GUARDIAN (REQUIRED)
I certify that I am the parent/legal guardian of ______(name of child), that I have read the foregoing Acknowledgement, Consent & Liability Release Form and I hereby agree to be bound by all of the obligations thereunder.
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Signature of Parent/Legal GuardianDate
CONSENT OF CHILD/STUDENTIF OVER 18 YEARS OF AGE
I am 18 years of age and am competent to contract in my own name. I have read this Acknowledgement, Consent & Liability Release Form before signing below and I fully understand the contents, meaning, and impact of this release and that this release is legally binding.
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Signature of Child/StudentDate
PERMISSION TO USE NAME; LIKENESS
Darien Safe Rides generates posters, flyers and other publicity to increase public awareness of the Program and its operations. The use of photos taken during a student’s/child’s activities is part of the publicity effort that helps the Program continue forward. Please consider helping us in this effort by granting permission for Darien Safe Rides to take, have taken and use: photographs, videotape, recordings, and/or digital images of the student/child (collectively, the student’s/child’s “Likeness”), including his/her name, for use in printed publications or materials, electronic/audio publications, social media or presentations, or on the Darien Safe Rides website, all without remuneration.
I grant permission for Darien Safe Rides to use my child’sname and Likeness for the uses stated above.
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Signature of Parent/Legal GuardianDate
I am 18 years of age and am competent to contract in my own name. I grant permission for Darien Safe Rides to use my name and Likeness for the uses stated above.
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Signature of Child/StudentDate