Adult/ Parent Name
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First Name
Last Name
Student Name
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First Name
Last Name
Parent Email
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Student Email (if above the 6th grade)
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Student Age
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Student Grade
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Student's School District
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What are the needs of the student? (Pre-Algebra help, ACT/SAT prep, After School Tutoring, College Admissions advice, etc.)
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Additional Information regarding the needs of the student?
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(If none, type "N/A")
I agree that I must check my email for the weekly tutoring/mentorship signups
Yes
No
Where did you learn about End the Cycle?
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Any comments/questions/suggestions for the End the Cycle Organization?
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Program / Event Name
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ETC Tutoring
Program/Event Dates (if more than 1 tutoring session, write just one possible date)
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Program/Event Location
Zoom
Child's Name (hereafter "Participant")
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First Name
Last Name
Participant's Date of Birth
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MM
DD
YYYY
PARTICIPATION AGREEMENT--I understand that my child’s participation in the Program is voluntary and that as a condition of my child’s participation, I agree to comply with all Program requirements including, but not limited to: (a) accurately completing all registration forms in a timely manner; (b) ensuring that my child is aware of the Program’s standards of conduct; and (c) immediately notifying the Program Administrator of any concerns related to the health, safety or security of my child, other participants, or Program staff.
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I agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
I DO NOT agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
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 have my child voluntarily participate in the Program, and engage in such activity knowing that the activity may be hazardous to my child and my property. I further understand that as part of my child’s participation in the Program that there are dangers, hazards and inherent risks to which my child may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. I further realize that participating in the Program may involve risks and dangers, both known and unknown, and I have chosen to allow my child to take part in the Program. Therefore, I, on behalf of myself and my child, have determined that it is reasonable to accept all risk of injury, loss of life or damage to property arising out of training, preparing, participating, and traveling to or from the Program and I, on behalf of myself and my child, do voluntarily accept and assume those risks. I acknowledge that employees of the University have undergone criminal background checks, but other participants of the Program may not have undergone background check screening. As such, the University makes no assertions or assurances with respect to other participants.
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I agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
I DO NOT agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
ACKNOWLEDGEMENT OF GOOD MENTAL AND PHYSICAL CONDITION I acknowledge that my child is in good mental and physical condition for the limited purpose of Program registration and participation.
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I agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
I DO NOT agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
CONSENT TO RECORDING AND COLLECTION OF INFORMATION -- I understand that during the course of my child’s participation in the Program, that the Program, and those acting with the Program’s permission or authority, may capture my child’s name, likeness, image, or voice in photographic, audio, video, digital or other recording forms (“Recordings”). I give my permission for the Program to use those Recordings or works produced by my child (e.g., art work) (“Works”) for promotional, commercial, informational, and educational purposes in any and all media (including the Internet) now existing or hereafter devised, for any purpose consistent with the Program’s mission. I understand that I will not have an opportunity to review or approve uses of the Recordings or Works. I recognize that the Program, through the University, holds the copyright in all Recordings and I, on behalf of myself and my child, grant the Program and the University a license to use the Works. I understand that neither my child nor I will receive payment or any other compensation for the taking or use of any Recordings or Works created as a result of my child’s participation in the Program.I release, indemnify and hold harmless the University from and against all liability, actions, debts, claims and demands of every kind whatsoever to the taking or use of the Recordings or Works of my child.I acknowledge that the University may collect information from me and my child. In addition, I acknowledge that the University may engage with third party service providers to provide online resources that will be used as part of the Program and that such third party service providers may collect information from me and my child. The third party service providers engaged for the Program are listed below. (zoom)
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I agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
I DO NOT agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
RELEASE AND WAIVER OF LIABILITY In consideration for the University allowing my child to participate in the Program, I, as parent and/or guardian of Participant, authorize my child to participate in the Program and release and discharge and hold harmless the University, its faculty, staff, students and all other officers, directors, employees, volunteers and agents from any claims or liability arising from my child’s participation in the Program, provided that such claim is not due to the gross and sole negligence of the released parties.This Agreement is governed by and construed under the laws of the State of Michigan without regard for principles of choice of law. Any claims, demands, or actions arising under this Agreement must be brought in the Michigan Court of Claims or a court with applicable subject matter jurisdiction sitting in the state of Michigan and I consent to the jurisdiction of a Michigan court with appropriate subject matter jurisdiction.I agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
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I agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
I DO NOT agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
Adult/Parent E-Signature
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Full name required
First Name
Last Name
Date of Signature
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MM
DD
YYYY