Media Consent and Release Form

For the purpose of promoting uCodeGirl's mission and activities, participants of uCodeGirl may be featured in materials to increase public awareness of our programs through newspapers, radio, TV, the internet, displays, brochures, and other types of media.

I, as the parent or guardian of the undersigned, hereby give uCodeGirl and its authorized employees, and authorized media representatives permission to print, photograph, and record my child(ren) for use in audio, video, film, or any electronic, digital and printed media.

a.     This is with the understanding that neither uCodeGirl nor its authorized representatives will reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child(ren)’s participation.

b.     I further release and relieve uCodeGirl, its board, employees, and other representatives from any liabilities, known or unknown, arising out of the use of this material.

I certify that I have read the Media Consent and Release Liability statement and fully understand its terms and conditions.

Participant Name *
Participant Name
Parent/Guardian Name
Parent/Guardian Name
Date
Date

Food Allergy Disclosure Form

This form allows the participant to disclose any food allergy or severe food allergy in order to enable uCodeGirl to take necessary precautions. “Severe food allergy” means a dangerous or life-threatening reaction of the human body to a food-borne allergen introduced by inhalation, ingestion, or skin contact that requires immediate medical attention.

Please list any foods to which you are allergic or severely allergic, as well as the nature of the allergic reaction to the food.   Please indicate no allergy if no allergy present. uCodeGirl will maintain the confidentiality of the information provided and may only disclose it to the appropriate personnel catering the food.  

Participant *
Participant
Parent/Guardian *
Parent/Guardian
Date *
Date

Agreement of Waiver of Liability, Indemnification, and Medical Release

Acknowledgement and Assumption of Risk

The undersigned parent and/or legal guardian does hereby acknowledge that he/she is aware of the dangers and the risks to the participant's person involved in participating in: uCodeGirl Crack the Code: STEM Mentorship for Girls. 

The undersigned parent and/or legal guardian and participant understand the STEM mentorship program will meet once a month for an in-person structured programming in a group setting, organized and facilitated by uCodeGirl. Outside of the scheduled sessions, mentor/mentee may only communicate virtually (by email or text) facilitated by uCodeGirl. Any one-on-one and/or in-person meetings are outside of the scope of uCodeGirl's Crack the Code: STEM Mentorship program and is the responsibility of the parents, mentors and mentees. uCodeGirl has no responsibility or liability for potential risks, injury or damage resulting from an in-person meeting.

The undersigned parent and/or legal guardian and participant understand that this activity involves certain risks for physical injury to the participant. We also understand there are potential risks of which may presently be unknown. Because of the dangers of participating in this activity, the undersigned parent and/or legal guardian and participant recognize the importance and the participant agrees to fully comply with the applicable laws, policies, rules and regulations, and any supervisors's instructions regarding participation in this activity.

The undersigned parent and/or legal guardian and participant understand that uCodeGirl does not insure participants in the above-described activity, that any coverage would be through personal insurance, and uCodeGirl has no responsibility or liability for injury resulting from this activity.

The undersigned parent and/or legal guardian acknowledges that the participant voluntarily elects to participate in this activity with knowledge of the danger involved, and hereby agrees to accept and assume any and all risks of property damage, personal injury, or death.

Waiver of Liability and Indemnification: In consideration for being allowed to voluntarily participate in the above-referenced event, on behalf of myself, the participant, his/her personal representatives, heirs, next of kin, successors and assigns, the undersigned parent and/or legal guardian forever: 

a)      waives, releases, and discharges uCodeGirl and its officers, board members and employees from any and all liability for the participant’s death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to the participant, and the participant’s estate as a direct or indirect result of participation in the activity or event; and  

b)      defend, indemnify, and hold harmless uCodeGirl, its officers, board members and employees, from any and all claims of any nature, including all costs, expenses, and attorney's fees, which may in any manner result from or arise out of this agreement, except for claims resulting from or arising out of the State's sole negligence.  

Consent is given for the participant to receive medical treatment, which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.  

I, the undersigned parent and/or legal guardian, affirm that I am freely signing this agreement. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to myself, the minor participant regarding any losses the participant may sustain as a result of participation in the activity. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

Participant *
Participant
Date *
Date