GIRLFLY STUDENT WAIVER FORM SUMMER 2021
To participate in Flyaway Productions GIRLFLY Program, this form must be signed and returned by May 25, 2020.
Student's Name*: Date of Birth*:
Parents/Guardian(s)*: Address*: City*: State*: Zip Code*: Parents Best Phone*: Email*: Preferred Mode of Communication: TelephoneEmail School*: Grade*:
Medical Information Health Plan/Insurance Company*: Policy/ID Number*: Doctor’s Name*: Doctor’s Telephone*: Pertinent Medical Information (allergies, medications, etc.)*: If necessary, is it acceptable to administer ibuprofen or other non-aspirin over-the-counter drug? YesNo
Emergency Contacts: 1. Name*: PH*: 2. Name*: PH*:
Dietary Restrictions*:
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Student's Name*:
I/We, the undersigned, parent/guardian(s) of the above-named student (the "Student"), hereby consent to the participation of the Student, in Flyaway Productions’ GIRLFLY Apprenticeship.
I/We acknowledge and agree that I/We will be responsible for transporting the Student to and from Flyaway Productions’ Arts and Activism Apprenticeship.
I/We further discharge and release Flyaway Productions and its trustees, officers, and employees, from any and all liability for injury, loss, damage, obligation, expense, or penalty sustained by the Student arising out of or in connection with the Student’s participation in the Arts and Activism Program.
In the event that any serious injury shall occur involving the Student, I wish for Flyaway Productions’ supervisory personnel to take appropriate steps to notify me immediately, but if I am inaccessible for any reason, I authorize whatever medical attention is deemed appropriate for the Student.
I/We understand the following Terms of Stipend/Attendance Policy of the Arts and Activism Apprenticeship:
Stipend of $500 is to be paid to each Student upon completion of the program. Checks will be hand delivered at the final performance.
Payment of stipend is dependent upon compliance with the following Attendance Policy: ABSENCES: Student is allowed 2 excused absences with advance notice to the program (students must call ahead), or absence due to illness or emergency. A 3rd absence will result in being asked to leave the program, and forfeiture of the stipend. LATENESS: Student is allowed one late arrival with no penalty. All late arrivals after that will result in $5 taken out of the stipend amount for each late arrival. Students may arrive 10 minutes late with no penalty. $5 will be taken away with every subsequent 10 minutes of lateness.
I/We hereby irrevocably consent to, and authorize the use and reproduction by Flyaway Productions, of any and all photographs, recordings, videotapes and/or other reproductions of likeness of the Student's person or characteristics ("reproductions") which have been secured for any purpose whatsoever, without compensation to the Student. All reproductions shall constitute the property of the Flyaway Productions, solely and completely. Further, I/We assign and release all right to said reproductions and authorize Flyaway Productions or others authorized by it, to exhibit, broadcast and/or distribute or otherwise further reproduce said reproductions in whole or in part over in any medium whatsoever, including, without implied limitation, newsletters, radio, newspapers, closed circuit television, film, cable, and television, with or without compensation in perpetuity. I/We also release, discharge and agree to hold harmless the producers or any persons, or entities acting under their permission of authority any liability arising from the use of said reproductions.
Your Name: ParentLegal GuardianParticipant 18 Years of Age or Older
Signature: Date:
------------ Authorization for Release of Confidential Information GIRLFLY/ Flyaway Productions
Participant Name:
Date of Birth:
Our agency is supported by a grant from the San Francisco Department of Children, Youth and Their Families (DCYF). As a condition of the funding we receive, we are required to report information about the services we provide and the children, youth, and families that we serve to DCYF. DCYF works in close partnership with the San Francisco Unified School District (SFUSD). The data that we report to DCYF is also shared with SFUSD.
By signing this form, you authorize our agency to share information about your child’s participation in our program (or your participation, if you are 18 years of age or older) with authorized staff at DCYF and SFUSD for the purposes described above. The information that we report to DCYF includes:
•Personal information, such as name, date of birth, and address; •Demographic information, such as race/ethnicity and gender identity; •Education information, such as school name and grade level; •Participation in activities and services, such as attendance dates and hours attended; and •Anonymous and voluntary youth experience surveys.
DCYF and SFUSD will not publicly report any information that we provide in a way that may be used to identify your child (or you, if you are 18 years of age or older).
Restrictions: All information that we provide that is related to an SFUSD student is protected by federal and state laws that govern the use, disclosure, and re-disclosure of student education records. Parties other than DCYF and SFUSD will not have access to any personally identifiable information that we report, except to the extent that the parties have obtained prior written authorization from you or have followed SFUSD policies and procedures to obtain access to such information.
Expiration: This authorization expires on June 30, 2023.
Your Rights: You may refuse to sign this form. You may cancel it at any time by informing our agency in writing. If you cancel your permission allowing us to release information to DCYF and SFUSD, it will go into effect immediately, unless the information has already been released. You have a right to receive a copy of this form.
DCYF Photography Release Form You or your child participates in a youth program funded by the San Francisco Department of Children, Youth, and Their Families (DCYF). DCYF staff or contractors may on occasion visit this program to take photographs for public information projects.
The public information projects aim to educate civic leaders and the general public about programs and services available for San Francisco children, youth and families. Example projects include DCYF publications and exhibits, as well as the DCYF website.
By signing this form, you authorize DCYF staff and contractors to take photographs of program activities that may include images of you or your child and to use these photographs for the public information projects described above.
Your Name: Relationship to Participant:ParentLegal GuardianParticipant 18 Years of Age or Older
------------ GIRLFLY Parent/Caregiver Acceptance Form 2021
Note: if you have multiple children enrolled in GIRLFLY, please complete a separate acceptance form for each child.
Child Name:
Flyaway Productions has accepted your child into the GIRLFLY 2021 program. Completion of this Acceptance Form is required in order to complete the enrollment process and confirm that your child(ren) will attend GIRLFLY. Within this acceptance form you will need to acknowledge that you have done the following:
Read and have received an electronic copy of the Health and Safety Plan for GIRLFLY.
Provided consent for your child(ren) to participate in GIRLFLY.
Health and Safety Acknowledgment
The collective effort and sacrifice of San Francisco residents staying at home limited the spread of COVID-19. But community transmission of COVID-19 within San Francisco continues, including transmission by individuals who are infected and contagious, but have no symptoms. Infected persons are contagious 48 hours before developing symptoms (“pre-symptomatic”), and many are contagious without ever developing symptoms (“asymptomatic”). Pre-symptomatic and asymptomatic people are likely unaware that they have COVID-19. The decision by the Health Officer to allow childcare and youth programs for all families at facilities that follow required safety rules does not mean that attending such programs is free of risk. Enrolling a child in summer programs could increase the risk of the child becoming infected with COVID-19. Each parent or guardian must determine for themselves if they are willing to take the risk of enrolling their child in a youth program, including whether they need to take additional precautions to protect the health of their child and others in the household. They should particularly consider the risks to household members who are adults 60 years or older, or anyone who has an underlying medical condition. Parents and guardians may want to discuss these risks and their concerns with their pediatrician or other health care provider. More information about COVID-19, MISC, and those at higher risk for serious illness is available on the Centers for Disease Control and Prevention website at https://www.cdc.gov/coronavirus/2019-ncov/.
I understand the risks associated with enrolling my child(ren) in GIRLFLY and agree to assume the risks to my child(ren) and my household. I also agree to follow all safety requirements that the youth program imposes as a condition of enrolling my child(ren).
I have reviewed Flyaway Productions Initiative Health and Safety Protocols at http://flyawayproductions.com/youth/
Final Acknowledgement of Intent to Enroll Child(ren) in GIRLFLY
I acknowledge that the information provided in this Form is accurate, and that I consent for my child(ren) to participate in GIRLFLY 2021.
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