49 Main St, Topsfield, MA 01983
TTC 2017 Boys Youth Mentee Program Waiver Form
December 9, 2017, December 16, 2017, January 6, 2018, January 27, 2018, February 10, 2018, March 3, 2018, March 17, 2018 and March 24, 2018 (snow date) NOTE: Program will take place at Masconomet from 6:30 - 8PM.
My child:______Grade:______Email:______
FirstLast
Address:______Parent Email:______
I, on behalf of my child and/or children, hereby indemnify, release, hold harmless, and forever discharge Tri-Town Council, the Town of Boxford, the Town of Topsfield, the Town of Middleton,Tri-Town School Unionand Masconomet Regional School District and its agents, employees, officers, directors, affiliates, successors, and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages, and liabilities, or every kind and nature, whether known or unknown, in law or equity, that I or my child ever had or may have, arising from or in any way related to my or my child’s or children’s participation in any activities conducted by, on the premises of, or for the benefit of Tri-Town Council, the Town of Boxford, the Town of Topsfield, the Town of Middleton, Tri-Town School Union andMasconomet Regional School District; provided, that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful, or wanton misconduct.
In the event I am unable to authorize medical decisions for my child or children or I cannot be reached on behalf of my child or children, I authorize and direct any adult activities sponsor, or group leader representing Tri-Town Council, the Town of Boxford,, the Town of Topsfield, the Town of Middleton,Tri-Town School Union and/or Masconomet Regional School District to make emergency medical decisions for my child.
Medical Conditions: My child is subject to the following allergies, dietary restrictions, or medical conditions, and I authorize the representatives of Tri-Town Council to disclose such allergies and medical conditions to the program chaperone(s) and to a physician in the event that my child should require emergency medical care.
Emergency Phone #’s:Cell:______Home:______Describe allergies, dietary restrictions, or medical conditions with specificity: ______
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Does your child receive any accommodation(s) during the regular school day?Yes____No____ If yes, please briefly state the nature of the accommodation: ______
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This information is required to determine if any reasonable accommodation(s) are required for your child to participate in the program. A parent/guardian may be responsible for any necessary accommodations such as hiring an aide or staying with their child during the program.
Photo Release (please check and initial): I hereby give permission ______I do not give permission ______for my child/ren to be photographed for use by the Tri-Town Council for program publicity.
My child______has my permission to participate in the Boys Youth Mentoring Program. I understand the terms above and I have willingly signed it as my own free act. I understand that attendance at all meeting dates is required in order to participate in this program. My child is available to participate on all scheduled meeting dates.
Parent/Guardian Signature: ______Date: ______
____ YES! I/we would like to be included on the youth email lists and the TTC general newsletter and Asset Tip of the week email (you may unsubscribe at any time).
Student Name: ______Grade: ______
The questions below will provide information that will help us match you with a mentor. Please feel free to add any additional information that you think will be helpful! Kindly submit question responses and completed waiver by November 30 to .
- What 3 words best describe your personality?
2. What interests do you have? What type of extra-curricular activities are you involved in?
3. What kind of books do you like to read?
- What kind of TV shows, do you like to watch and/or what kind of video games do you like to play?