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Parent/Guardian Consent To Participate and Waiver for Youth Circle Keeper Training Program

This program is an educational, supportive, community-oriented youth program. Activities may include group discussion, reflection, mindfulness exercises, and guided conversation.

I understand that the program will take place in a library meeting room and will be supervised by Liliana Barzola. I understand that this program is educational in nature and is intended to provide a respectful, low-key, and supportive environment for youth participants.

Group Discussion and Sensitive Topics: I understand that the program may include group discussion and educational conversation. Some topics may be personal, emotional, or sensitive, depending on the program content and participant questions.

Examples of possible topics may include: identity, friendships, family communication, stress, school experiences, community issues, civic engagement, technology, or other relevant topics.

The organizer will make reasonable efforts to create a respectful and age-appropriate environment. However, I understand that participants may share personal opinions or experiences during group discussion.

I understand that this program is not a substitute for counseling, therapy, medical care, legal advice, or crisis support.

Behavior and Participation Expectations: I understand that my child is expected to participate respectfully, follow reasonable instructions from program staff, and treat other participants, staff, library property, and community members with care. I understand that the organizer may contact me or require my child to leave the program if my child’s behavior becomes unsafe, disruptive, or inconsistent with the purpose of the program.

Assumption of Risk: I understand that this is a low-risk educational program, but participation may still involve ordinary risks, including minor accidents, emotional discomfort from discussion topics, or interactions with other participants.

Permission for Emergency Medical Care: If I cannot be reached in an emergency, I give permission for Circle Keeper Training Staff to seek emergency medical care for my child, including calling 911, contacting emergency medical services, or arranging transportation to a medical facility if needed. I understand that every reasonable effort will be made to contact me as soon as possible. I understand that I am responsible for any medical costs or expenses related to emergency care for my child, to the extent permitted by law.

I Release and Liliana Barzola, their agents, employees, successors and assigns, and their respective heirs, personal representative, affiliates, and any or all persons, liable or who might be claimed to be liable, whether or not here in named, none of whom admit any liability to the undersigned, from claims or liability arising from my child’s participation in the program, except in cases of gross negligence, willful misconduct, or other liability that cannot be waived under applicable law. d paste the body of your waiver here.

Parent or Guardian's Email Address
Email*
Confirm Email*
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First Participant's Name Name
First Name*
Last Name*
First Participant's Name Age Acknowledgment*
First Participant's Name Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Name Signature*
Second Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Third Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Fourth Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Fifth Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Sixth Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Seventh Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Eighth Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Ninth Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth
Tenth Participant's Name Name
First Name*
Last Name*
Participant's Name Date of Birth*
Date of Birth

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. I am the parent or legal guardian of the child named above. I give permission for my child to participate in Circle Keepers Training.



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