GIRLFLY STUDENT WAIVER FORM
SUMMER 2019

To participate in Flyaway Productions GIRLFLY Program, this form must be signed and returned by June 1, 2019.

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*:

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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 Apprenticeship.

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 3 excused absences with advance notice to the program (students must call ahead), or absence due to illness or emergency. A 4th 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. Students will be docked $1 for every time they use a cell phone or electronic devise during program hours without permission.

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:

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