P.O. Box 5235, Burlington, VT 05402

Transportation Consent Form

Dear Parent(s)/Guardian(s):

Please read the following consent form regarding the SEXPO conference at Green Mountain College and

sign, date, and return it to Outright Vermont, P.O. Box 5235, Burlington, VT 05402 by November 12,

2011. YOUTH WILL NOT BE ALLOWED TO TRAVEL WITH OUTRIGHT VERMONT WITHOUT A SIGNED

PERMISSION SLIP.

In case of an emergency, you may reach Outright Vermont staff on the day of the event by calling (802)

777-8220.

Authorization

• It is my wish that my youth enjoy the experiences afforded to the participants of SEXPO and I

fully understand that, even after reasonable precautions have been taken, some activities may

involve hazards for which Outright Vermont cannot be held responsible.

• It is also understood that Outright Vermont has permission to use photographs or videotapes

taken of my youth while participating at SEXPO in question for promotion and various

publications. Youth participants have the option to opt out of photographs/video if they choose.

• In signing this form, I certify that health and accident insurance or Medicaid covers my youth

and that I am obliged to provide Outright Vermont with the name of the carrier and policy

number(s) if requested.

• To preserve confidentiality, Outright Vermont will not release information about its program

participants to outside sources without the consent of both the youth and their parent or

guardian, unless the information released is in the aggregate and has no personally identifying

features, or in response to a court order, or is subject to mandatory reporting under Vermont

statute.

• In signing this form, I give consent for a representative from Outright Vermont to transport my

youth to the event in question. By signing, I agree to personally wait or arrange for a responsible

person to wait with my youth at the assigned pick up location AND be present or arrange for a

responsible person to be present at the appointed drop off time and location to pick up my

youth.

I have read and agree to the terms and policies contained herein. I give consent for my youth to travel

with a representative from Outright Vermont.

Parent/Guardian Signature: _________________________________ Date: _______________________

Print Name: __________________________________________________________________________

Please include your primary telephone number AND a backup number in case of an emergency:

_____________________________________________________________________________________

Green Mountain College Presents Our Annual

Join Green Mountain College Presents Our Annual:

AN EXCITING EXPO CHOCK FULL OF:

FABULOUS SPEAKERS AND PRESENTERS! Student Lead Workshops:

Body Positivity, Health and Wellness, Sexual Education,

Consent, Safety and More! Plus Fun Games, Raffles and an

Open Mic! also SNACKS (OMG)!

Workshops start at 1:00pm

EXPO at 7:00

November 19, 2011

SEXPO!