Assumption of Risk and Liability Release

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					                  G-CAPP and GYUPP Atlanta Regional Training
                               April 16th, 2011
   Trinity United Methodist Church * 265 Washington Street * Atlanta, GA 30303


                           PERMISSION SLIP: Under 18
If you are under 18, please have your parent or guardian sign this form.
         Please fax or email this form by April 13th, 2011 to Lauren Fields

   Fax: 404-523-7753 or lauren@gcapp.org
   Mail: Georgia Campaign for Adolescent Pregnancy Prevention (G-CAPP)
         1450 W. Peachtree Street, Suite 200, Atlanta, GA 30309



I___________________________________________________ give permission for
                     (Parent/Guardian name)
___________________________________________________ to attend the GYUPP
                    (Youth name)
Regional Training on Saturday, April 16th, 2011 from 1:30 – 5:00pm.

This training offers a wonderful educational opportunity for young adults to learn about
and have discussions around sex and sexuality, contraceptives, relationships, and
becoming an advocate. Lauren Fields, a G-CAPP staff member, will be at this training
with the youth at all times. If you have questions about what will be covered during the
training, please contact Lauren Fields, G-CAPP Youth Leadership Coordinator, at
lauren@gcapp.org or (404) 475-6047.


Signature of Parent/Guardian            Printed name of Parent/Guardian

____________________________            ____________________________
Date                                    Best Contact Number

____________________________            ____________________________
Emergency Contact Name                  Emergency Contact Number
                       GYUPP and G-CAPP Atlanta Regional Training
                                    April 16th, 2011
    Trinity United Methodist Church * 265 Washington Street * Atlanta, GA 30303


               Assumption of Risk and Liability Release: Under 18
If you are under 18, please have your parent or guardian sign this form. Parent/Guardian:
after reviewing this form, please fill out all information and place your signature where
required, authorizing your child’s participation in Savannah Regional Training event.
            Please fax or email this form by April 13th, 2011 to Lauren Fields
    Fax: 404-523-7753 or lauren@gcapp.org
    Mail: Georgia Campaign for Adolescent Pregnancy Prevention (G-CAPP)
          1450 W. Peachtree Street, Suite 200, Atlanta, GA 30309

Participant’s Name________________________________________Age_________________________
Address_____________________________________________________________________________
City________________________________                                     Zip Code______________________
Home Phone_________________________                                      Cell Phone____________________

I, __________________________ the parent and/or guardian of _____________________, assume the
risks of personal injury and/or property damage that is incurred by my child in participating in the training.
I further agree to indemnify G-CAPP for any personal injury or property damage caused by my child. I
understand that any violation of rules may result in termination of my child’s attendance in the program
and/or judicial charges.

I understand that the training participants will stay at and attend training sessions at Trinity United
Methodist Church in Atlanta, GA. I further understand that G-CAPP has no liability regarding
transportation of my child to and from the training or while my child is participating at the training and that
my child travels at his/her own risk.

I hereby release any and all rights for claims and damages I may have against G-CAPP or its trustees,
officers, employees and agents, including staff members and supervisors, in any manner due to any
personal injury or property loss sustained by me or my child as a result of his/her participation in the G-
CAPP training. I will not hold G-CAPP responsible for liability for injury or damages arising from the result
of my child’s participation in this program unless it is due to willful or intentional misconduct or negligence
on the part of G-CAPP.

My child is not yet 18 years of age. I have read the above statement and agree to its terms.


Parent/Guardian Signature________________________________________________Date__________
Parent’s Name________________________________________________________________________
Parent’s Telephone Numbers (h)__________________(w)____________________(c)_______________
Parent’s Address______________________________________________________________________
Parent’s Email Address_________________________________________________________________

				
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