Father's First Name
Last Name
Middle Initial
Email
Cell Phone
Home Address
Work/Other Phone
Occupation
Employer
Mother's First Name
Last Name
Middle Initial
Email
Cell Phone
Home Address
Work/Other Phone
Occupation
Employer
Child First Name
Last Name
Middle Initial
Nickname
Birthplace
Date Of Birth
Help the Guide get to know your child:
Alternate persons to contact in case of an emergency:
List all allergies and special precautions or treatments:
List any medications currently being administered:
List any physical or developmental disabilities and any special needs:
List diseases the child has had (chicken pox, etc.):
Primary Physician:
Immunization record (may attach record from physician):
G SUITE FOR EDUCATION NOTICE AND CONSENT
At Acton Academy Northwest Indianapolis, we use G Suite for Education, and we are seeking your permission to provide and manage a G Suite for Education account for your child. G Suite for Education is a set of education productivity tools from Google including Gmail, Calendar, Docs, Classroom, and more used by tens of millions of students and teachers around the world. At Acton Academy Northwest Indianapolis, learners will use their G Suite accounts to complete assignments, communicate with their guides, sign into their Chromebooks, and learn 21st century digital citizenship skills.
The notice linked here provides answers to common questions about what Google can and can’t do with your child’s personal information, including:
What personal information does Google collect?
How does Google use this information?
Will Google disclose my child’s personal information?
Does Google use student personal information for users in K-12 schools to target advertising?
Can my child share information with others using the G Suite for Education account?
Please read it carefully, let us know of any questions, and then agree below to indicate that you’ve read the notice and give your consent. If you don’t provide your consent, we will not create a G Suite for Education account for your child and your child will not be able to use a Chromebook and other web-based tools.
Child's Name
Parent/Guardian:
Today's Date
WAIVER AND RELEASE OF LIABILITY
In consideration of being allowed to participate in any way in Acton Academy Northwest, Indianapolis, LLC. related events and activities, the undersigned:
Agree that the parent(s) and/or legal guardian(s) of the participant should inspect the facilities and equipment to be used, and if the parent or guardian believes anything is unsafe, he or she should immediately advise supervisor (advisor, manager, etc.) of such condition(s) and refuse to participate.
Acknowledge and fully understand that each member/participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions, or negligence but the action, inaction, and negligence of others, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time.
Assume all the foregoing risks and accept personal responsibility for the damage following such injury, permanent disability or death.
Release, waive, discharge and covenant not to sue Acton Academy Northwest Indianapolis, LLC. its affiliated clubs, their respective administrators, directors, agents, and other employees of the organization, other members/participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors or premises used to conduct the event, all of which are hereinafter referred to as “releases,” from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury, including death and damage to property, caused or alleged to be caused in whole or in part by the negligence of the releases or otherwise.
Child's Name
Parent/Guardian:
Today's Date
PHOTO RELEASE
As you know, when your child works on projects or participates in activities we often have many great photo and video opportunities. We would like your permission to use photographs and videos taken during lab time, exhibitions, field trips, special events or celebrations to post internally in the classroom, hallway, sharing with parents, guide training, and as a historical
We also would like your permission to use photographs and videos of your child for publicity purposes on a brochure, website and other types of promotional materials. When photographs or videos are used for publicity purposes, children are never identified by name. All photos and videos used for publicity will be available for the child’s parents to review upon request. In addition, parents reserve the right to request that any photograph or video not be used for publicity.
Child's Name
Parent/Guardian:
Today's Date
CONSENT AND RELEASE FORM FOR FIELD TRIP TRANSPORTATION
My child has permission to participate in field trips (which includes service-learning projects) and I understand that these activities involve travel to and from the location of the field trip.
I also understand that private drivers, which may include a guide, volunteer, or parent/guardian of another student participating in the activity (“released parties”), may be used to transport children to and from the activity. Acton Academy Northwest Indianapolis' insurance does not cover damages arising from, or related to, the operation of any private vehicle, failure to follow the directed driving route, or any personal negligence related to this activity. Any damages/harm resulting from a parent/guardian or other designated driver, arising from the operation of a motor vehicle in relation to the above listed activity, is hereby waived.
I also understand that I have the ability to refuse to consent to this Form. In addition, that if I refuse to consent, I must provide transportation for my child in order for my child to participate in the activity. I also acknowledge that Indiana law requires children to be in a car or booster seat until the age of 8. If my child requires a car or booster seat, I must provide one in order for my child to attend the trip. If a car or booster seat is not provided, my child will not be able to attend the trip.
My child has my permission to travel with a private driver on field trips. I hereby release Acton Academy Northwest Indianapolis and its agents/volunteers, from responsibility for any difficulties, medical expenses, or injuries which may arise in connection with field trip transportation.
Child's Name
Parent/Guardian:
Today's Date
Parent/Guardian:
Today's Date
Submit
