Fillable PLEASE EMAIL THIS COMPLETED FORM TO Iain Campbell, (Montgomery County Community College)

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PLEASE EMAIL THIS COMPLETED FORM TO Iain Campbell, (Montgomery County Community College)

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Page 1 of 4
PLEASE EMAIL THIS COMPLETED FORM TO
Iain Campbell, Program Coordinator for Cultural Affairs and the Lively Arts Series
icampbell@mc3.edu | 215-619-7309
(if not):
Camper Information
Camper first Name:
Camper last Name:
Camper Email:
Street Address:
City:
State:
Zip:
Date of Birth:
Home phone:
List any allergies or dietary restrictions:
Parent Information
Name:
Parent email:
Check here if address is the same as camper address above:
Street Address:
City:
State:
Zip:
Home Phone:
Mobile phone:
Work phone:
Relationship to camper: Mother Father Guardian
Other:
22323
PARTICIPANT AND PHOTO CONSENT, RELEASE AND
WAIVER OF LIABILITY FOR ONLINE PROGRAMS/ACTIVITIES
READ CAREFULLY BEFORE SIGNING
I acknowledge and represent that l am the parent/guardian of a child attending, via a digital platform, a
Montgomery County Community College summer camp and I desire my child to participate in this camp.
hereby
RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE
TO INDEMNIFY AND HOLD HARMLESS for any and all purposes SPONSOR, The
MONTGOMERY COUNTY COMMUNITY COLLEGE, the UCF BOARD OF TRUSTEES, the STATE
OFFLORIDA and the FLORIDABOARD OF GOVERNORS and their respective officers, servants,
agents, volunteers, or employees (herein collectively referred to as MCCC)
FROM ANY AND ALL
LIABILITIES, RESPONSIBILITIES, CLAIMS, DEMANDS, CAUSES OF ACTION OR
INJURY, INCLUDINGDEATH, that may be sustained by my child, or to any property belonging to
me or my child, whether caused by the negligence of the MCCC or otherwise, while participating in the
Program, or while in, on or upon the premises where the Program is being conducted
.Program activities may include, but are not limited to the following:
• Virtual group conversations
• Interactive learning sessions in an online platform
IDENTIFICATION AND ACKNOWLEDGMENT OF RISK
I am fully aware of the risks and potential hazards connected with participating in the Program, including
but not limited to, the risk of data mining, phishing, viruses, malware, data breach of online information
cyberbullying, exploitation, victimization, cyber stalking, online grooming, cyber predators, digital
footprint, reputation loss, compliance violations, brand hijacking, image replication, and I hereby elect to
voluntarily participate in the Program, and engage in such activity knowing that the activity may be
hazardous to my child and/or my or my child’s property.
I VOLUNTARILY ASSUME FULL
RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY
DAMAGE OR PERSONAL INJURY, that may be sustained by my child, or any loss or damage
to property owned by me, as a result of my child being engaged in such an activity,
WHETHER
CAUSED BY THE NEGLIGENCE OF MCCC or otherwise.
‘
ACKNOWLEDGEMENT OF GOOD MENTAL AND PHYSICAL CONDITION
I further acknowledge that my child is in good mental and physical condition for the limited purpose of
Program registration and participation, I hereby give permission for the Montgomery County Community
College to collect information from me and my child through an online platform. I understand that this
information will not be shared with any third party, unless otherwise required by the third-party platform
provider for participation, or unless required by law, regulation, and/or university policy.
CONSENT TO RECORDING
I further hereby authorize the Montgomery County Community College to photograph and video/audio
record (“Record”) my child during the Program, and use or distribute any photograph, audio or video
recording (“Materials”) related to Program activities that my child is depicted in. I also authorize use of
these Materials for publication in a brochure, on Montgomery County Community College websites, or
other Montgomery County Community College promotional material. Materials may also be distributed
to other Program participants, or the public for educational purposes, including but not limited to a
Program group photograph of all participants.
RELEASE AND WAIVER OF LIABILITY
I HEREBY EXPRESSLY RECOGNIZE AND ASSUME ALL RISKS ASSOCIATED
WITH MY CHILD’S PARTICIPATION IN THE PROGRAM AND VOLUNTARILY
RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE AND HOLD
HARMLESS THE MCCC. I AGREE TO INDEMNIFY AND HOLD HARMLESS the
MCCC from any loss, liability, damage or costs, including court costs and attorneys’ fees, that may be
incurred due to my child’s participation in the Program,
WHETHER CAUSED BY THE
NEGLIGENCE OF MCCC or otherwise. It is my express intent that this Online Participation
Agreement and Waiver Form shall bind the members of my family and spouse, if I am alive, and my heirs,
assigns and personal representative, if I am deceased, and shall be deemed as a
RELEASE, WAIVER,
DISCHARGE AND COVENANT NOT TO SUE the above-named MCCC. I hereby further agree
that this Participant Release, Consent and Waiver of Liability shall be construed in accordance with
the laws of the State of Florida.
IN SIGNING THIS PARTICIPANT CONSENT, RELEASE AND WAIVER OF LIABILITY, I
ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing, understand it and sign it
voluntarily as my own free act and deed; no oral representations, statements, or inducement, apart
from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and
fully competent and I am the parent or guardian of the child participant, and I execute this
Participant Consent, Release and Waiver of Liability for full, adequate and complete consideration,
fully intending to be bound by same.
Printed Parent or Guardian Name:
Date:
Signature of Parent or Guardian:
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PLEASE EMAIL THIS COMPLETED FORM TO Iain Campbell, (Montgomery County Community College)

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Completed 3 October 2020

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