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STEM Teens Leadership Council | Permission/Liability Release

Permission Agreement: As parent or guardian of the below named student, I hereby grant permission for my child to participate in the STEM Teens Leadership Council of The Academy of Science of St. Louis. As long as he/she is a member of the STEM Teens Leadership Council, I hereby grant permission for my child to participate in any and all programs of the STEM Teens Leadership Council, including field trips, both on and off school grounds (each a “Teen Science Café STEM Teens Leadership Council Activity”). I agree that this permission cannot be revoked with respect to The Academy of Science of St. Louis while my child is a member of the STEM Teens Leadership Council. To the fullest extent allowed by law, on behalf of me and my child I hereby (i) waive and discharge any and all claims of any kind against the Academy Parties, arising out of my or my child’s participation in any STEM Teens Leadership Council Activity (ii) release the Academy Parties from any and all liability resulting from injuries and damages to me or my child arising out of or because of my or my child’s participation in any STEM Teens Leadership Council Activity, even if caused by negligence of one or more of the Academy Parties; and (iii) defend, indemnify, and hold harmless the Academy Parties from any claims, damages, injuries, or losses which are in any way connected with my or my child’s participation in any STEM Teens Leadership Council Activity, even if such claims allege negligent acts or omissions of one or more of the Academy Parties. The foregoing provision will survive termination of my child’s membership in the STEM Teens Leadership Council. The "Academy Parties" means The Academy of Science of St. Louis and all of its affiliates, agents, directors, trustees, officers, consultants, employees, and persons or entities acting in any capacity on its or their behalf in connection with the STEM Teens Leadership Council. I hereby agree that The Academy of Science of St. Louis may use my child’s name and/or photograph in any promotional and/or informational materials, including its website. The foregoing provision will survive termination of my child’s membership in the STEM Teens Leadership Council.

Participant's
Minor
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First Student Participant Name

First Name*

Middle Name

Last Name*
First Student Participant Age Acknowledgment*
First Student Participant Date of Birth*
I certify that I am 18 years of age or older
First Student Participant Information

Student Nickname
Gender (This question is asked for purposes of understanding our population better and fulfilling grant reporting requirements. Thank you!)*

Student Home Street Address *

City *

State *

Zip Code *

School *

Current Grade *

High School Graduation Year *

Student Email *

Student Phone Number (xxx.xxx.xxxx) *
Student Phone Number is:*
Cell
Home

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email *

Parent/Guardian Home Street Address (if different from student)

City

State

Zip Code

Parent/Guardian Primary Phone Number (xxx.xxx.xxxx) *
Parent/Guardian Primary Phone is:*
Cell
Home
Work

Parent/Guardian Secondary Phone Number (xxx.xxx.xxxx) *
Parent/Guardian Secondary Phone is:*
Cell
Home
Work

2nd Parent/Guardian First Name (enter N/A if deceased, or none) *

2nd Parent/Guardian Last Name (enter N/A if deceased, or none) *

2nd Parent/Guardian Email (enter N/A if deceased, or none) *

2nd Parent/Guardian Home Street Address (if different from student)

City

State

Zip Code

2nd Parent/Guardian Primary Phone Number (enter N/A if deceased, or none) *
2nd Parent/Guardian Primary Phone is:*
N/A
Cell
Home
Work

2nd Parent/Guardian Secondary Phone Number (enter N/A if deceased, or none) *
2nd Parent/Guardian Secondary Phone is:*
N/A
Cell
Home
Work

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Cell or Primary Phone Number (xxx.xxx.xxxx) *
First Student Participant Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Student Nickname
Gender (This question is asked for purposes of understanding our population better and fulfilling grant reporting requirements. Thank you!)*

Student Home Street Address *

City *

State *

Zip Code *

School *

Current Grade *

High School Graduation Year *

Student Email *

Student Phone Number (xxx.xxx.xxxx) *
Student Phone Number is:*
Cell
Home

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email *

Parent/Guardian Home Street Address (if different from student)

City

State

Zip Code

Parent/Guardian Primary Phone Number (xxx.xxx.xxxx) *
Parent/Guardian Primary Phone is:*
Cell
Home
Work

Parent/Guardian Secondary Phone Number (xxx.xxx.xxxx) *
Parent/Guardian Secondary Phone is:*
Cell
Home
Work

2nd Parent/Guardian First Name (enter N/A if deceased, or none) *

2nd Parent/Guardian Last Name (enter N/A if deceased, or none) *

2nd Parent/Guardian Email (enter N/A if deceased, or none) *

2nd Parent/Guardian Home Street Address (if different from student)

City

State

Zip Code

2nd Parent/Guardian Primary Phone Number (enter N/A if deceased, or none) *
2nd Parent/Guardian Primary Phone is:*
N/A
Cell
Home
Work

2nd Parent/Guardian Secondary Phone Number (enter N/A if deceased, or none) *
2nd Parent/Guardian Secondary Phone is:*
N/A
Cell
Home
Work

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Cell or Primary Phone Number (xxx.xxx.xxxx) *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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