2022 TCG Memorial Academy Summer Experience

Scholar (Student) Name*

First

Last

Date of Birth*

day

/

month

/

year

Parent/Guardian Name #1*

First

Last

Parent/Guardian Name #2

First

Last

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone*

Email*

Any Allergies or Health Concerns? If yes, please specify, as well as any medication or special care required.*

Does your scholar have access to a Chromebook or laptop for use in Technology Curriculum during the program?*

Yes

No

2021-2022 School of Attendance *

2022-2023 School of Attendance*

COVID-19 PANDEMIC PARTICIPATION CONSENT FORMAssumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World HealthOrganization. COVID-19 is extremely contagious and is believed to spread mainly from person-toperson contact. As a result, federal, state, and local governments and federal and state healthagencies recommend social distancing and have, in many locations, prohibited the congregation ofgroups of people.Terrell Christopher Gladney Memorial Academy (hereby referred to as TCG Memorial Academy) has put in place preventative measures to reduce the spread of COVID-19;however, TCG Memorial Academy cannot guarantee that you or your child(ren) will not becomeinfected with COVID-19. Further, attending TCG Memorial Academy events could increase your riskand your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending this event and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the event (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless TCG Memorial Academy, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.*

Parent Name (Electronic Signature) This will serve as your electronic signature confirming your child's participation in our program:*

Today's Date (For Confirmation of Signature)*

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