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ASTRO

Arts, Sports, and Technology Resource Organization

Liability Release and Informed Consent

DISCLAIMER

The Arts, Sports, and Technology Resource Organization (herein ASTRO) and its leaders, directors, officers, employees, contractors, agents, volunteers, members, and representatives, are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, competitions, mentorships, volunteer opportunities, seminars, vocational services, psycotherapeutic services, programs, activities or travel with ASTRO and all related activities associated with ASTRO, including any injury, loss, or damage. This Liability Release and Informed Consent does not constitute accpetance into any ASTRO programs or services. A Program Coordinator will notify you in writing if you have or have not been accepeted into the program.

PHOTO/IMAGE RELEASE

Occasionally, we will take pictures and/or conduct video recordings during ASTRO programs and events. ASTRO uses the pictures and/or videos on our website and on our social network sites like Instagram, Facebook, and Snapchat, for promotional outreach and fund development capacities. We will never reference you or your child by name or provide specific information regarding you or your child. We also will never sell these pictures and videos; we will use them exclusively for ASTRO social networks and aforementioned purposes. By signing this form, you grant ASTRO permission to use photo and video recordings of you or your child in our promotional materials. 

I Agree

ASSUMPTION OF RISKS

IN CONSIDERATION OF ASTRO allowing me or my child to participate in events, classes, psychotherapeutic services, competitions, programs, activities or travel with ASTRO and all related activities associated with ASTRO, including participation in classes, therapy groups, programs, mentorships, volunteer opportunities, seminars, offerings, and all events inclusive, and all activities related to ASTRO, I acknowledge that I am aware of the possible Risk, Dangers, and Hazards associated with participation in activities including the possible risk of severe or fatal injury to myself, my child, or others.

RELEASE OF LIABILITY and AGREEMENT

1. TO ASSUME and ACCEPT ALL RISKS arising out of, associated with or related to my or my child’s participation in the activities.

I Agree

2. TO WAIVE and RELEASE ASTRO from any and all liability for any loss, damage, injury, death, or expense that I or my child may suffer, or that my next of kin may suffer as a result of mine or my child’s participation of the activities due to any cause whatsoever.

I Agree

3. TO INDEMNIFY and HOLD HARMLESS ASTRO from any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from my or my child’s participation in the activities.

I Agree

4. TO INDEMNIFY and HOLD HARMLESS ASTRO from any and all claims, demands, actions, and costs for any loss, injury, damage or expense whatsoever that may arise out of my or my child’s participation in the activities.

I Agree

PARTICIPATION CONSENT

Acknowledgement of Member: 

I, the undersigned Member, understand that I am responsible to act in a safe and responsible fashion, to follow the instructions or directions of the persons in charge of ASTRO activities, and to obey requests and comply with the safety regulations as directed by the persons in charge (and outlined in the ASTRO code of conduct document), including designated leaders and drivers of private or public transportation. I will be solely responsible for myself, will wear a seatbelt when available and will not disturb or distract the driver when using private or public transportation to travel to and from activities. At all sports events and other activities, I acknowledge that it is my responsibility to obtain and wear appropriate safety equipment. I will not endanger the safety of myself or others at any activities, outings or sports events hosted by ASTRO or when using private or public transportation for travel to and from such activities. I also understand that I may be photographed or appear in video for such purposes as ASTRO deems necessary. 

I Agree

Acknowledgement of Parent/Guardian of Participant

I, the undersigned Parent or Guardian of the Member, hereby authorize and consent to the Member’s involvement in ASTRO classes, programs, psychotherapeutic services, seminars, offerings, and events inclusive, and all activities related to ASTRO, including any use of private or public transportation deemed necessary by the persons in charge of the event for Member to travel to and from activities, or to the NEAREST SUITABLE MEDICAL FACILITY or HOSPITAL FACILITY in the event that emergency or other medical treatment is not available at the site of an activity and is deemed advisable. I hereby consent to and authorize such emergency or other medical treatment of the Member as may be deemed advisable in the event of accident, injury, illness, or death during the activities of ASTRO. I also understand that the Member may be photographed or appear in video for such purposes as ASTRO deems necessary. 

I Agree

COVID-19 Agreement for Children and Staff Attending In-person Programming

Types of service:    

ASTRO offers special events, competitions, mentorships, volunteer opportunities, seminars, vocational services, psycotherapeutic services, programs, activities, and transportation to and from offerings for qualified members. Appropriate dress code required for each program will be outlined in porgram brochures given to participants and families prior to start date. By initialling, I agree that the member applying for this program is available to attend all the dates listed in the program brochure and meets all the necessary requirements to participate as defined there in.

I Agree

Program Sessions

In order to attend I and my child agree that: 

  • Everyone in your home will assess themselves for signs of COVID19 using the COVID-19 Screening Tool assessment (https://www.reopeningri.com/resource_pdfs/COVID19_Screening_Tool_English-NEW.pdf). If they indicate they have any of the symptoms, they will report this to the secretary at 401-255-2911
    I Agree
  • If anyone in the home has a fever or shows signs of being ill, they must be tested for COVID19 and found to be negative before resuming programming
    I Agree
  • Prior to each session you will be available to complete and sign COVID-19 Screening Tool for yourself or on behalf of your child and attest to the accuracy of your/their body temperature reading at that time. Persons who have a fever of 100.40 (38.00C) or above or other signs of illness will not be admitted to the facility or bus
    I Agree
  • All will wash hands upon entering ASTRO
    I Agree
  • All individuals will follow rules and guidelines in the 2021 General Policy (Covid-19 Compliance) displayed on site at ASTRO 
    I Agree
  • All group participants must maintain social distancing from other stable groups in the program and must wear a mask at all times. There will be designated spots to help everyone keep the appropriate distance during transitions. 
    I Agree
  • I understand that completion of this waiver does not mean my child has been accepted in to the program. Parents will be notified by the Program Coordinator if their child is accepted into the program or not. 
    I Agree

These guidelines are signed herein by the member and parent or approved guardian if under the age of 18.  

Services may be put on hold if the above guidelines are not followed or if the return of the pandemic results in a stay at home order from the State of Rhode Island.

https://www.cdc.gov/coronavirus/2019-ncov/downloads/COVID19-symptoms.pdf

https://www.reopeningri.com/resource_pdfs/COVID19_Screening_Tool_English-NEW.pdf

https://www.cdc.gov/coronavirus/2019-ncov/downloads/stop-the-spread-of-germs-11x17-en.pdf

ACKNOWLEDGEMENT and SIGNATURE

I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT that is binding upon myself and my heirs, executors, administrators, successors, and/or assigns. I HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT and I ACKNOWLEDGE THAT by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that I, or my child may have.

I Agree

This Consent, Authorization and Acknowledgement shall be effective on September 17, 2021.

Please select who will be participating...
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First Member's Name

First Name*

Last Name*

Phone*
First Member's Date of Birth*
First Member's Information

School currently attending or current employer
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Does your child have an IEP or 504 plan?*
No
Yes
N/A if over 18

If you or your son/daughter has a medical diagnosis please list that here
(For minors under age 18) Does your child have permission to walk to and from the program?*
Yes
No
N/A (if participant is over the age of 18)

(For minors under age 18) If your child is being picked up from the facility, please list the names of persons authorized to pick up your child. Each person listed must present a valid ID that matches the name entered below.


Authorized Person #1

Authorized Person #1 Telephone number

Authorized Person #2

Authorized Person #2 Telephone number
First Member's Signature*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to sign up for our newsletter.
Health Concerns/Emergency Contacts

List all allergies (to include foods), health problems, medications, or other physical or mental health concerns we should know about: *

Emergency Contact #1 Name *

Emergency Contact #1 Phone Number *

Emergency Contact #2 Name *

Emergency Contact #2 Phone Number *

Insurance Carrier *

Insurance Policy # *
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

School currently attending or current employer
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Does your child have an IEP or 504 plan?*
No
Yes
N/A if over 18

If you or your son/daughter has a medical diagnosis please list that here
(For minors under age 18) Does your child have permission to walk to and from the program?*
Yes
No
N/A (if participant is over the age of 18)

(For minors under age 18) If your child is being picked up from the facility, please list the names of persons authorized to pick up your child. Each person listed must present a valid ID that matches the name entered below.


Authorized Person #1

Authorized Person #1 Telephone number

Authorized Person #2

Authorized Person #2 Telephone number
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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