Student Information for Waiver & Permission
* Student Name
Student Cell Phone
Student Cell Phone
* Current Address
Date of Birth
* Date of Birth
All shirt sizes are in adult
Prefer Not To Choose
Is your student a 21st Century Scholar?
No, but I would like help signing my student up for it
Guardian Cell Phone
* Guardian Cell Phone
Guardian #2 Cell Phone
Guardian #2 Cell Phone
Guardian #2 Email
Emergency Contact Information
Food or Airborne Allergies
Any medical conditions that we should be aware of?
RELEASE, WAIVER OF LIABILITY AND INDEMNIFICATION
By signing below electronically, I hereby agree to release and hold harmless D.R.E.A.M. Alive, Incorporated, its affiliates, subsidiaries, employees, officers, directors, employees, and the Indianapolis Colts Organization from and against all liability as a result of my student’s participation in ALL APPROVED D.R.E.A.M. Alive, Incorporated programming and/or events. Moreover, as the parent(s) and/or legal guardian(s) of the above-referenced student, I agree to indemnify and hold D.R.E.A.M. Alive, Inc. and it’s agents, employees, individual staff and volunteer harmless against any and all claims, liabilities, losses, damages, or expenses of any kind, including reasonable attorney fees, sustained as a result of participation in any and all after-school programming and/or events held by D.R.E.A.M. Alive, Incorporated.
SCHOLAR PROGRAMMING AND TRIPS:
I give my child permission to participate in D.R.E.A.M. Alive, Inc. Programming and attend field Enrichment trips sponsored and/or hosted by D.R.E.A.M. Alive, Inc. to local establishments, businesses, colleges, universities and attractions throughout Indiana and surrounding states. I hereby grant permission of my son/daughter to be transported by D.R.E.A.M. Alive, Inc. staff and other program instructors in conjunction with attendance and activities directly related to his/her participation in ALL D.R.E.A.M. Alive, Inc. programming held at approved after-school programming sites and venues. Programming includes, but not exclusive to, ALL D.R.E.A.M. partnerships, sponsorships, and collaborations, whether taking place daily, weekly, monthly, annually or otherwise.
I understand every reasonable precaution will be taken to safeguard my child at all times. Furthermore, I understand adequate and appropriate supervision will be provided at all times during programming.
I have read the above provisions and I do hereby give my permission for my child to fully participate in all after-school Programming, attend field trips and/or outside events/activities sponsored by D.R.E.A.M. Alive, Incorporated and be transported by D.R.E.A.M. Alive, Incorporated and/or its designated agents or contractors.
I understand that the student, my child participates in D.R.E.A.M. Alive, Incorporated programming, events, trips, and activities at his/her own risk.
Guardian Electronic Signature for Release and Waiver of Liability
* Guardian Electronic Signature for Release and Waiver of Liability
By typing your name here (the guardian), you are entering into a legally binding agreement with DREAM Alive, agreeing to the release, waiver of liability and indemnification as specifically written above.
Date of Signing
* Date of Signing
I grant to D.R.E.A.M. Alive, Inc. the exclusive right to use my child's interview/photograph/video or film likeness in media and promotional materials. I authorized others to use all or any part of my child’s interview, photograph, video in related media such as books, magazines, journals, pamphlets, electronic (internet) and other written and video formats. The undersigned also releases D.R.E.A.M. Alive, Inc and its directors, its members, trustees, founders, officers, employees, partners, and agents, as well as the Indianapolis Colts and its agents, from any and all claims, demands, causes of action and suits, including by not limited to, claims for invasion of privacy, defamation, breach of contract or other breach of duty arising out of or in connection with the use of any interview, photograph, video or other media representations.
Thank you for completing the Scholar Waiver. A member of the DREAM Alive staff will be contacting you shortly to confirm your waiver.