Girl's First Name (the “Participant”): *

Girl’s Last Name: *

Nickname (for name tag):

Name of School: *

Grade Level (PositivelyMe! is for 3rd Grade girls only)

Address: *

Address 2:

City: *

State: *

Zip: *

Age *

Date of Birth: *

T-shirt size of girl participant: *

Parent/Guardian's First Name: *

Parent/Guardian's Last Name: *

Relationship to Participant: *

Best Contact Number for Parent/Guardian (also to be used in the event of an emergency): *

Email Address for Parent/Guardian: *

Session Information

Please rank your choice of weekend. Please note that this year's Positively Me sessions are going to be at the JLG House. *

	Fri.-Sat. February 2-3, 2024
	Fri.-Sat. March 1-2, 2024
	Fri.-Sat. April 5-6, 2024

* Junior League House- 231 EAST Putnam Avenue, Greenwich, CT 06380

Alternative Emergency Contact Information

* Name of Person(s) to notify in case of an emergency(if Parent/Guardian cannot be reached)

First Alternate Emergency Contact Person: *

Relationship of First Alternate Emergency Contact Person to Participant: *

Phone Number of First Alternate Emergency Contact Person: *

Second Alternate Emergency Contact Person:

Relationship of Second Alternate Emergency Contact Person to Participant:

Phone Number of Second Alternate Emergency Contact Person:

The PositivelyMe Program Indemnity/ Release of Liability

The “PositivelyMe!” Program Indemnity/Release of Liability:

As parent/guardian of the participant’s name, I agree for myself, my child, my (our) heirs, executors, legal guardians and administrators (collectively, the “Releasor”) to indemnify and hold harmless the Junior League of Greenwich and their respective members, officers, directors, administrators, employees, representatives and agents (collectively, the “Releasee”) from and against any and all loss, cost, expense, fees (including legal fees), liability (arising from injury or otherwise), damage, claim, demand, suit, or cause of action, of any nature whatsoever for any act or omission arising from my child’s participation in this program and any related activities. On behalf of the Releasor, I further accept the risk of unforeseen circumstances arising from this program and release, remise, waive and forever discharge the Releasee from any and all liability (for injury or otherwise), loss, damage, claim, demand, suit or action arising from my child’s participation in any activities located at, sponsored by or otherwise coordinated by the Junior League of Greenwich (specifically including this program and any services or performances provided by third party contractors for this program.

Confidentiality:
As a general rule, The Junior League of Greenwich and its Releasee will keep information shared during this program confidential. In some situations, the Releasee is required by law or by the guidelines of its profession to disclose information without permission.

Jurisdiction:
This Consent shall be interpreted, construed and enforced in accordance with the laws of the State of Connecticut. If any legal action arises out of or is in any way connected with my child’s participation in this program, I consent to the exclusive jurisdiction of any State or Federal Court located in the State of Connecticut having subject matter jurisdiction and waive any objection to such venue or convenience of such forum.

In case any one or more of the provisions contained in this Consent shall for any reason be held to be invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and this Consent shall be construed as if such invalid, illegal or unenforceable provision had never been contained herein.

I HAVE READ THIS CONSENT, I FULLY UNDERSTAND ITS TERMS AND THEIR LEGAL EFFECT, AND I HEREBY SIGN IT FREELY AND VOLUNTARILY. I FURTHER STATE THAT I AM THE PARENT/GUARDIAN OF THE CHILD NAMED HEREIN, THAT I AM COMPETENT TO SIGN THIS CONSENT, AND THAT I CONSENT TO MY CHILD’S PARTICIPATION IN THIS PROGRAM IN CONSIDERATION OF THE TERMS SET FORTH HEREIN.

Guardian Name *

Guardian Signature *

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Child Release Information

The participant will not be released to anyone other than a parent or legal guardian unless the name is listed below, or you send written consent for your child to leave with someone else. This is for the participant’s protection. We may ask for identification if we are unsure of the person picking up the participant.

Please list anyone else who has permission to pick up the participant, below. *

Medical and Emergency Contact Information (to be called in case of an emergency):

Name of Doctor or Practice *

Phone Number of Doctor or Practice *

Name of Dentist *

Phone Number of Dentist *

Does the participant have any allergies (e.g. food) or other health issues you would like us to be aware of? *

Yes

No

If Yes, Please Describe:

Do you give permission for photographs to be taken of the participant to be used for public relations materials? (No names or school information will be shared) *

Yes

No

Covid-19 Release

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk of potential exposure despite all of the precautions taken by Junior League of Greenwich. A copy of the Junior League of Greenwich COVID-19 protocols are attached. To the greatest extent permitted by law, I hereby release, discharge and hold Junior League of Greenwich, its representatives and members harmless from any personal injury, illness, or death to the participant.

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

Guardian Name *

Guardian Signature *

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One last thing...

How did you hear about the PositivelyMe! program?: *

Youth Small	Youth Medium	Youth Large	Adult Small	Adult Medium
Adult Large