youTHink: MLK Community Service Event - Jan 2014

8/13/2019 youTHink: MLK Community Service Event - Jan 2014

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A program of the Zimmer Children’s Museum

6505 Wilshire Boulevard 100 Los Angeles, CA 90048

Phone: (323) 761-8311 Fax: (323) 761-8990

www.youthink.org

RETURN THIS NO LATER THANWednesday, January 15, 2014

Engaging Students in Contempo rary Issues and Civic ction Through rt

youTHink Field Trip Permission Form

I hereby grant permission for my child to participate in the following event:

Destination: MLK Day Community Service EventHorace Mann Middle School7001 S. St. Andrew PlaceLos Angeles, CA 90047

Date: Monday, January 20, 2014

Departure Time: 7:30 am Return Time: 3:00 pm

I understand that transportation will be by: Shuttle / Bus .

youTHink Staff will call participating students a few days before the event to confirm the pickup times, pickuplocation and other trip details. Please feel free to call Lucy Mendez at 323-761-8318 or 323-364-3187 for details

I understand that adequate and appropriate supervision will be provided. I recognize, however, thatunanticipated situations and problems can arise on any trip, which situations or problems are not reasonablywithin the control of the supervising youTHink and/or Zimmer Children’s Museum staff (including volunteers).In such instances, I agree that the Zimmer Children’s Museum and the supervising youTHink and/or ZimmerChildren’s Museum staff (including volunteers) are not to be held legally responsible in the event of accident orinjury and I will hold the Zimmer Children’s Museum and the supervising youTHink and/or Zimmer Children’s

Museum staff (including volunteers) harmless from any costs, liability, or related expenses.

I give permission for emergency medical attention to be administered should that be necessary while on thisfieldtrip. I also give my permission for photos of my child taken while participating in youTHink programs to beused in promotional materials for youTHink and the Zimmer Children’s Museum, which may include aninstitutional video, website, or brochures.

Emergency Contact Information: During the fieldtrip, I can be reached at:If unable to contact parent/ guardian, in case of emergency, please call: (name, relationship and phonenumber)

Student’s name: __________________________ School: _______________________________________

Address: _________________________________ City, State, Zip: ________________________________

Grade: _____ Birth date: _____________ Email: ______________________ _________________________

Student’s Cell Number: _______________________________ Home Number: ________________________

Parent/Guardian’s Signature: ______________________________

Print Parent/Guardian’s Name: _____________________________________

Please note: Submitting a permissionslip does NOT guarantee your child’sparticipation at the event. Space islimited and youTHink Staff reserves theright to select students based ontransportation capacity and otherprogram considerations.

http://www.youthink.org/





6505 Wilshire Boulevard 100 Los Ángeles, CA 90048Teléfono: (323) 761-8311 Fax: (323) 761-8990

www.youthink.org

ENTREGAR ESTA FORMA ANTES DELMiercoles 15 de Enero , 2014

Iniciando a Los Estudiantes En Temas Modernos y Acción Cívica a Través de Arte

Permiso para el paseo con youTHink

Yo/Nosotros otorgamos permiso para que mi hija/hijo participe en el evento:

Destino: MLK Day Community Service EventHorace Mann Middle School7001 S. St. Andrew PlaceLos Angeles, CA 90047

Fecha: Lunes 20 de Enero del 2014

Hora de Salida: 7:30 am Hora de Retorno: 3:00 pm

Entendemos que el transporte será a través de: Autobús/Camión

Personal de youTHink llamará a los estudiantes participantes unos días antes del evento para confirmarlas horas de recolección, el lugar de recolección, y otros detalles del viaje. Por favor, llamen a LucyMendez a 323-761-8318 o 323-364-3187 para detalles.

Entendemos se proporcionará supervisión adecuada y apropiada. Reconocemos sin embargo, quepueden surgir situaciones y problemas imprevistos en cualquier viaje, problemas que no están bajo elcontrol del supervisor de youTHink o del Museo Infantil Zimmer (incluyendo sus voluntarios). En talescasos, nosotros convenimos en que ni el Museo Infantil Zimmer ni el supervisor o los voluntarios de

youTHink y/o del Museo Infantil Zimmer deberán ser hechos legalmente responsables. En caso deaccidente o herida, mantendremos a todo el personal de youTHink y/o el al Museo Infantil Zimmer(incluyendo a los voluntarios) libre de cualquier costo, obligación, o gastos relacionados a este.

Yo/Nosotros otorgamos permiso para que se administre cualquier atención médica en caso de unaemergencia durante este paseo. Yo/Nosotros también otorgamos permiso de utilizar fotografías tomadasdurante este paseo para publicaciones y materiales promociónales de youTHink y del Museo InfantilZimmer, al igual que videos institucionales, página de Internet folletos y ocasionalmente periódicos.

Durante el paseo, podré ser contactada/o al: En un caso de emergencia enel que no sea posible contactar a padres/guardianes, favor de llamar a al número

(como esta relacionada esta persona? Tío? Tía? Abuela? Etc.)

Nombre del estudiante: Escuela: ____________

Domicilio: __ Ciudad, Estado, Código Postal: ___________________________

Grado: ______ Correo electronico:_______________________ Fecha de nacimiento: ______________

Número celular de estudiante: ___ Número telefónico: ____________

Nombre en imprenta de padre/guardián: ____________

Firma de padre/guardián: ________________________

Por favor tenga en cuenta que presentar una

forma de permiso NO garantiza la participacion

de su hijo/a en el evento. El personal youTHink,

reserva el derecho de seleccionar a los

estudiantes en base de la capacidad del

transporte y los objetivos del evento.






Youth Volunteer Liability Waiver

For volunteers under 18 years of age

Participant’s NamParticipant’s NamParticipant’s NamParticipant’s Name:e:e:e:_________________________________________

Participant’s Affliation:Participant’s Affliation:Participant’s Affliation:Participant’s Affliation: ______________________________________

Parent or Legal GuardianParent or Legal GuardianParent or Legal GuardianParent or Legal Guardian NameNameNameName:________________________________

Email:Email:Email:Email:_______________________________ Phone Number:Phone Number:Phone Number:Phone Number: _______________________

Name of Event:Name of Event:Name of Event:Name of Event: ___________________________________________

Please check the appropriate boxes:

I have participated in at least one City Year service day previously.

I would like to receive updates about City Year and the different opportunities to getinvolved in the community.

1. Participation Waiver1. Participation Waiver1. Participation Waiver1. Participation Waiver –––– To be filled out by Parent or Legal GuardianTo be filled out by Parent or Legal GuardianTo be filled out by Parent or Legal GuardianTo be filled out by Parent or Legal Guardian

As the parent/legal guardian of above named minor, I do hereby consent to his/her participation in

voluntary projects, events, and functions sponsored and/or organized by City Year. I understand thathe/she is responsible for his/her behavior, and that he/she will only participate in events or performvolunteer work that he/she is comfortable with. I do hereby waive and release City Year, their servicepartners and/or sponsors from all claims or liabili ties, of any kind whatsoever, arising, whetherdirectly or indirectly, from the above-named minor’s participation in City Year’s organized and/orsponsored projects, events or functions.

Signature of Parent/Legal Guardian _________________________Date______________

2. Photograph and Information Release2. Photograph and Information Release2. Photograph and Information Release2. Photograph and Information Release

City Year is committed to furthering the discussion and growth of national service in the public

realm. As such, I grant permission for City Year to use any photos, film, digital imaging, videos,verbal and/or written statements, pertaining to the above stated participation in City Year’sorganized and/or sponsored projects, events or functions, of the above stated participant, a minor,or their likeness for promotional, web or other uses by City Year.

Signature of Parent/Legal Guardian___________________________Date______________

If you have any questions, please call Bernadette Morales, Corporate Relations & Events Manager at(213) 596-5895 or [email protected].



Adult Volunteer Liability WaiverFor volunteers 18 years of age or older.

Participant’s NameParticipant’s NameParticipant’s NameParticipant’s Name: __________________________________________________

Participant’sParticipant’sParticipant’sParticipant’s Company:Company:Company:Company: _______________________________________________

Email:Email:Email:Email:____________________________________ Phone Number:Phone Number:Phone Number:Phone Number: ___________________

Name of Event:Name of Event:Name of Event:Name of Event:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check the appropriate boxes:

I have participated in at least one City Year service day since July 2012.

I would like to receive updates about City Year and the different opportunities to get involved in thecommunity.

1. Participation Waiver1. Participation Waiver1. Participation Waiver1. Participation Waiver

I understand that I am spending time as a volunteer on projects organized by City Year withnonprofit groups, or participating in a City Year event or function. I understand that I am responsiblefor my behavior, and I will only participate in events or perform volunteer work that I am comfortablewith. Having read this waiver, knowing these facts and in acceptance of my participation in City

Year’s organized and/or sponsored projects, events, and functions I, for myself and anyone entitledto act on my behalf, waive and release City Year, their service partners and/or sponsors from allclaims or liabilities, of any kind whatsoever, arising, whether directly or indirectly, from myparticipation in City Year’s organized and/or sponsored projects, events or functions.

Signature ___________________________________________ Date______________________

2. Photograph and Information Release2. Photograph and Information Release2. Photograph and Information Release2. Photograph and Information Release

City Year is committed to furthering the discussion and growth of national service in the publicrealm. As such, I grant permission for City Year to use any photos, film, digital imaging, videos,

verbal and/or written statements, pertaining to the above stated participation in City Year’sorganized and/or sponsored projects, events or functions, of the above stated participant, a minor,or their likeness for promotional, web or other uses by City Year.

Signature _____________________________________________ Date____________________

If you have any questions, please call Bernadette Morales, Corporate Relations & Events Manager at(213) 596-5895 or [email protected].

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youTHink: MLK Community Service Event - Jan 2014