The Help Group's Kaleidoscope Registration & Release form
Out & About Summer Program For LGBTQ+ teens and allies (ages 14-18,) including those who identify as neurodivergent.
Product Name Emergency Information Child's Name *
Child's Date of Birth *
Date Format: MM slash DD slash YYYY
Child's Home Address
* Child's Gender Identity * Child's Preferred Pronouns * Parent/Guardiant One's Name *
Parent/Guardiant One's Home Phone * Parent/Guardiant One's Work Phone * Parent/Guardiant One's Cell Phone * Parent/Guardiant One's Email *
Parent/Guardiant Two's Home Phone Parent/Guardiant Two's Name
Parent/Guardiant Two's Work Phone Parent/Guardiant Two's Cell Phone Parent/Guardiant Two's Email
Child's Allergies (if any) Primary Physician's Name *
Primary Physician's Phone
IN THE EVENT OF AN EMERGENCY I GIVE PERMISSION FOR THE HELP TO CONTACT AND OR RELEASE MY CHILD ONLY TO THE FOLLOWING PERSONS:
* Phone * Relationship to Child * Name *
* Phone * Relationship to Child * Release and Waiver of Liability and Indemnity Agreement
In consideration of being permitted to participate in any activities involved with The Help Group’s camp programs, the undersigned, for himself or herself and any participating student for whom I am a parent or guardian (the “Student”), as well as other parents, guardians, any heirs, assignees, next of kin, distributees, and legal representatives of the Student, hereby enter into this agreement (the “Agreement”). Please read the terms and conditions of this Agreement carefully, as they impose legal obligations on you. By the terms “you” and “your” we refer to participants in the Activities, as well as to a parent or guardian signing this Agreement properly on behalf of a student who at the time this Agreement is signed is under the age of 18.
I certify that the named participant below is healthy and capable of participating in all activities without restriction. I understand that it is solely my responsibility to determine whether there is any medical reason that he/she should not participate in an activity. If there are limitations or restrictions from certain kinds of activities, please specify:
1. I am aware that the Activities may be hazardous. I am voluntarily participating in these activities, or authorizing the Student to participate in these activities with knowledge of the risks involved. I hereby agree to accept any and all risks of injury, accident or fatality and verify this statement by placing my initials here:
2. I, for myself, the Student, as well as any other parents, guardians, any heirs, assignees, next of kin, distributees, and legal representatives of the Student do hereby release, waive, discharge, and covenant not to sue The Help Group and all its affiliated entities and programs ( collectively “THG” ) and, its directors, officers, employees, and agents (collectively, “Releasees”) from all liability to the undersigned or the Student, and to any other parents, guardians, heirs, assignees, next of kin, distributees, and legal representatives of the Student for any loss or damage, and any claim or demands therefor on account of injury to the person or property or resulting in death of the undersigned or the Student, while the undersigned or the Student is participating in any way in the Activities.
3. I hereby agree to indemnify and save and hold harmless the Releasees and each of them from any loss, liability, damage or cost they may incur, including attorneys’ fees and costs, due to my participation in the activity, or the participation of the Student, whether caused by the negligence of the Releasees or otherwise.
4. I hereby assume full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releasees or otherwise while I, or the Student is participating in any way in the Activity.
I further expressly agree that the foregoing Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of California and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I have read this Agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing this Agreement freely and voluntarily, and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Electronic Signature of Parents/Guardians *
(Please type your full name)
The Help Group Policies: POLICY REGARDING THE REPORTING OF CHILD ABUSE
California law requires that all professionals who work with, care for, or otherwise come in contact with children, must report all known or suspected cases of child/dependent adult abuse and neglect.
Abuse is defined as any instance of physical abuse, physical neglect, sexual abuse, or emotional maltreatment.
If an employee of The Help Group has reason to believe that any kind of child/dependent adult abuse has occurred, a report will be made to the appropriate authority and parent/guardian will be notified.
Please sign below that you have read and understand the policy regarding the reporting of child abuse.
POLICY REGARDING THE HANDS-ON MANAGEMENT OF BEHAVIOR
Only staff persons certified in CPI may use hands-on management as a behavior intervention procedure and ONLY as an intervention in the following circumstances:
a. The child is assessed to be in danger of harming themself; and/ or
b. The child is assessed to be in danger of harming others; and/or
c. The child is assessed to be in danger of harming themself or others in the process of misusing, abusing or destroying physical property
The goal of the intervention procedure is to ensure the safety of the child, his or her peers, and the staff. In all cases, the dignity and human rights of the child must be safeguarded. Under no circumstances may any hands-on management of behavior be accompanied by any inflictive or retaliatory acts, nor may mechanical restraint of any kind may be used.
All episodes of hands-on interventions must be documented and submitted to the appropriate administrator for review and parent notification.
Please sign stating that you have read all of these policies and agree to comply with them if your child is accepted into the STEM3 Academy program.
Photo/Video/Audio/Name Release *
I hereby give consent for my child to appear in photographs, slides, video tape, DVD, CD, film, audio tape or any other medium for use by The Help Group. I understand that any or all of these media materials may be used by The Help Group for public relations, fundraising, training, demonstration, and/or educational purposes.
I hereby give consent for my child’s name and or the family surname to be used for public relations, fundraising, training, demonstration, and/or educational purposes by The Help Group. I waive any and all rights to compensation for any use of these media materials.
TERMS OF ACCEPTANCE and SIGNATURE
I, parent or guardian of minor child, certify that I have read and understood the applicant instructions for The Help Group ‘s camp programs included with this application and that answers given by me to the foregoing questions and statements made by me are complete and true to the best of my knowledge and belief.
I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application.
I understand that this application form is intended for use in evaluating me or my minor child’s qualifications for The Help Group ‘s camp programs and that this application is not considered as an acceptance to The Help Group ‘s camp programs.
I, the (applicant, requestor, etc) for this release agreement, warrant the truthfulness of the information provided in this application.
Electronic Signature of Parents/Guardian of Minor *
(Please type your full name)
Date Format: MM slash DD slash YYYY