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Info-Waiver-Release of Liability Form.doc - Grand Rapids

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									                          20xx-20xx YOUTH ADVISORY COMMITTEE
                        INFORMATION, WAIVER AND RELEASE OF LIABILITY FORM

Student Name:
Home/Mailing Address:
City:                                          Zip Code:
Phone Number:                                 E-mail:
Date of Birth:
School:                                                                                  Current Grade:
Name of Parent(s):
Are your parents living together or apart?
If they are apart, with whom do you reside?

         In consideration of the opportunity to participate in Youth Advisory Committee1 activities sponsored by the Grand Rapids
Community Foundation or its geographic component funds2 during the school year listed above, the undersigned acknowledges,
understands and agrees with the following:
          The undersigned Youth Advisory Committee member (hereinafter “YAC”) and/or the undersigned parent or legal guardian of the
YAC member who is under the age of 18, on behalf of himself or herself or the member under the age of 18, waive(s), release(s) and
agree(s) to hold harmless the Grand Rapids Community Foundation, its affiliates, representatives, agents, officers, board members,
employees and volunteers (“the Releasees”) from any liability to the undersigned and the personal representatives, heirs, assigns, and family
of the undersigned.
            This waiver and release of liability by the undersigned Grand Rapids Community Foundation YAC member applies to all activities
related to YAC membership including, but not limited to, meetings, conferences, annual overnight leadership camps, transportation to and
from any Grand Rapids Foundation YAC event, as well as activities in which the undersigned/member participates during the event(s)
including, but not limited to, walking, hiking, bicycling, swimming, and other rigorous activities that are physically and mentally challenging,
for all loss or damages on account of injury or harm to the member or to the property of the member, whether caused by the negligence of
the Releasees or otherwise.
Media Release: This waiver and release of liability further applies to news releases and the nature and content of media stories and reports
that may result from news releases. Any photographs or videotapes of the undersigned Grand Rapids Community Foundation YAC member
engaging in activities sponsored by the Grand Rapids Community Foundation may be reproduced and utilized in promotional activities,
publications, or other media events.
                        INDIVIDUAL AND/OR PARENTAL CONSENT/WAIVER & RELEASE OF LIABILITY
The undersigned has/have read this Waiver and Release of Liability and has/have voluntarily signed it, representing and
warranting that the YAC member is at least 18 years of age or, in the alternative, that the undersigned is the YAC member’s
parent or legal guardian.



Youth Advisory Committee Member                                                             Date


Parent/Legal Guardian                                                                       Date




1   “Youth Advisory Committee” or “YAC” and Youth Grant Committee are synonymous.
2   Geographic Component funds include Wyoming, Ionia, Southeast Ottawa and Sparta Community Foundations.

								
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