Media Consent and Release Form
For the purpose of promoting uCodeGirl's mission and activities, participants of uCodeGirl STEM Mentorship 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 undersigned, hereby give uCodeGirl and its authorized employees, and authorized media representatives permission to print, photograph, and record me 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 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.
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.
Agreement of Waiver of Liability, Indemnification, and Medical Release
Acknowledgement and Assumption of Risk
The undersigned does hereby acknowledge that 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 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 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 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 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 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, 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.
I am a volunteer providing my professional mentorship services (“Volunteer”) to uCodeGirl, a Nonprofit Organization (“Organization”). I shall hold in trust for the sole benefit of the Organization any materials, information or ideas that are provided to or otherwise made available to me, the Volunteer by the Organization, or otherwise obtained or learned in connection with the execution of the project whether before or after the date hereof (“Confidential Information”). As Volunteer I shall not use, reproduce or disclose any Confidential Information except to the extent necessary to execute the project or as authorized by the organization’s Executive Director. In any event, except as authorized by the organization’s Executive Director I shall not disclose any Confidential Information to any person other than individuals within the organization who have a need to know such Confidential Information.
The Organization materials including, without limitation, the Organization course module, the Organization program package, all documents, drawings, graphs, models, sketches, designs, lists and other information furnished to me by Organization or which are designated in writing to be the property of Organization, and all copies thereof, are owned by the Organization may not be duplicated, shared, distributed, sold or otherwise used, except (i) for the purpose for which it is intended by Organization, or (ii) for any other purpose Organization may hereafter authorize in writing. I understand that all participants ideas and documents are the sole property of the mentees. I understand and agree that any enhancements to any Organization materials that I create become the property of the Organization.
I acknowledge and agree, as a condition to participating in the uCodeGirl STEM Mentorship for Girls program, that I will not compete with Organization by using Organization materials, teachings or methodology with any other individuals or groups at any time, or starting up a similar youth STEM mentorship program for a period of three years from the later of (a) the date of this agreement, and/ or (b) the date on which my volunteer efforts on behalf of Organization end. I understand that Organization is relying upon my promises as a condition to providing me with Organization mentor training materials permitting me to volunteer or work for the Organizationprogram.