MAA Consent Forms 13-14 Copy
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MESTIZO ARTS ACTIVISM COLLECTIVE Parent/Legal Guardian Signature Date PARENT / LEGAL GUARDIAN CONSENT FORM R ELEASE & INDEMNIFICATION : I hereby recognize that my child’s participation in this pr ogram may involve bodily and/or emotional injury. In consideration of my child being permitted to participate in such events, I for myself, my child, my heirs, any executors and administrators, hereby voluntarily release negligence based on an y injury, except that cause solely by the willful misconduct of the Mestizo Arts & Activism Collective staff, that may result from my child’s participation. EMERGENCY TREATMENT: I hereby authorize Mestizo Arts & Activism Collective staff to act on my behalf in accordance with their best judgment in case of emergency involving my child, and agree to assume full responsibility for all expenses, medical, or otherwise that may arise there from. I understand that my insurance company or I will be billed for such emergency treatment. TRANSPORTATION PERMISSION: I hereby understand my child or ward will be released to the Mestizo Arts & Activism Collective on the designated Program dates. I hereby give my permission for the Mestizo Arts & Activism Collective to transport my child/ward to and from the P rogram sites for fieldtrips to the Utah State Capitol, The University of Utah, a nd other Program event sites. I hereby agree and vo luntarily assume risk, which be associated with or result from my child’s or ward’s transportation to the Mestizo Arts & Acti vism Collective. I further agree to release Mestizo Arts & Activism Collective and University of Utah, its agencies, departments, officer, employees’ age nts, and all sponsors and/or officials and staff of any said entity or pe rson, the representatives, liability, claims, demands, actions, and causes of a ctions whatsoever for any loss, my child or ward arising out of any and all activity associated with the aforementioned activities. I have carefully read and understand the contents of this form concerning the transportation of my child or ward to or from the program sites. PHOTO PERMISSION: I give permission for photographs and videotape recordings of my son/daughter’s participation in activities Mestizo Arts & Activism Collective to be used in promotional materials for this programs. I understand that photos and/or videos may be used in brochures, edited video programs, online and other promotional items for informing interested parties about the Mestizo Arts & Activism Collective. EQUAL OPPORTUNITY: Mestizo Arts & Activism Collective provides equal opportunity to participants regardless of race, creed, gender or ability to pay, and will upon request provide reasonable accommodations to individuals with disabilities. By signing this document, I acknowledge that I have read its contents a nd disclosure, and that I agree to its terms.
Transcript of MAA Consent Forms 13-14 Copy
7/27/2019 MAA Consent Forms 13-14 Copy
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MESTIZO ARTS & ACTIVISMCOLLECTIVE
Parent/Legal Guardian Signature Date
PARENT / LEGAL GUARDIAN CONSENT FORM
R ELEASE & INDEMNIFICATION: I hereby recognize that my child’s participation in this program may
involve bodily and/or emotional injury. In consideration of my child being permitted to participate insuch events, I for myself, my child, my heirs, any executors and administrators, hereby voluntarily
release negligence based on any injury, except that cause solely by the willful misconduct of the MestizoArts & Activism Collective staff, that may result from my child’s participation.
EMERGENCY TREATMENT: I hereby authorize Mestizo Arts & Activism Collective staff to act on my behalf in accordance with their best judgment in case of emergency involving my child, and agree to
assume full responsibility for all expenses, medical, or otherwise that may arise there from. I understandthat my insurance company or I will be billed for such emergency treatment.
TRANSPORTATION PERMISSION: I hereby understand my child or ward will be released to the Mestizo
Arts & Activism Collective on the designated Program dates. I hereby give my permission for theMestizo Arts & Activism Collective to transport my child/ward to and from the Program sites for
fieldtrips to the Utah State Capitol, The University of Utah, and other Program event sites.
I hereby agree and voluntarily assume risk, which be associated with or result from my child’s or ward’stransportation to the Mestizo Arts & Activism Collective. I further agree to release Mestizo Arts &
Activism Collective and University of Utah, its agencies, departments, officer, employees’ agents, andall sponsors and/or officials and staff of any said entity or person, the representatives, liability, claims,
demands, actions, and causes of actions whatsoever for any loss, my child or ward arising out of any andall activity associated with the aforementioned activities.
I have carefully read and understand the contents of this form concerning the transportation of my child
or ward to or from the program sites.
PHOTO PERMISSION: I give permission for photographs and videotape recordings of my son/daughter’s
participation in activities Mestizo Arts & Activism Collective to be used in promotional materials for this programs. I understand that photos and/or videos may be used in brochures, edited video programs,
online and other promotional items for informing interested parties about the Mestizo Arts & ActivismCollective.
EQUAL OPPORTUNITY: Mestizo Arts & Activism Collective provides equal opportunity to participantsregardless of race, creed, gender or ability to pay, and will upon request provide reasonableaccommodations to individuals with disabilities.
By signing this document, I acknowledge that I have read its contents and disclosure, and that I agree to
its terms.
7/27/2019 MAA Consent Forms 13-14 Copy
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MESTIZO ARTS & ACTIVISMCOLLECTIVE
I, ____________________________ (Print Parent/Legal Guardian Name), understand the hazards that
may result from my child’s or ward’s participation in the Mestizo Arts & Activism Collective. By
signing this document, I give permission to my son/daughter ____________________________
(Print Student Name) to participate in the 2013-2014 Mestizo Arts & Activism Collective cohort.
Parent/Legal Guardian Signature Date
The Mestizo Arts and Activism Collective (MAA) is a university-community partnership located in the
Westside of Salt Lake City, Utah. We seek to develop community-engaged leaders and scholars by
providing a space for high school students to strengthen their leadership, critical thinking, and
community-based research skills. We seek to create a safe environment for high school-age students to
discuss issues that affect their age-group, including issues impacting their families, friends and
communities on a daily basis (e.g. education, stereotypes, immigration, bullying, etc.). Drawing from
critical ways of teaching and learning we begin to unpack these issues and respond to them by creating
projects that address these community concerns (e.g. websites, documentaries, newspapers articles,
murals, music, dance, etc.). Our goal is to make a difference through developing young leaders, creating
unity within our community and informing the world about problems young people of color face.
**Please return this copy to the Mestizo Arts & Activism Collective by Monday, October 21, 2013**
If you have any questions, please contact Alonso Reyna at [email protected] or 801-703-
7346; or to access a copy of this document, please visit: http://www.maacollective.org
