Lindell General Acknowledgement of Risks and Release of Liability Permission Form
This form is intended for the parents/guardians of minors who plan to attend activities sponsored by Lindell Study Center and hosted at Lindell or an off-site location.

This form need only be filled out once for the 2020/2021 academic year and covers non-overnight activities.

Activities include, but are not limited to:

After school study groups (Circles) hosted at Lindell
E-Street middle school girls club
Avenue-E high school leadership program
Lindell sponsored off-site outings or service opportunities
Days of Recollection (Mini-Retreats)

For more information about Lindell programs, please visit:
Sign in to Google to save your progress. Learn more
Email *
Full Name of Student *
Parent/Guardian Phone *
Emergency Contact Name and Number *
Please list any Medical conditions of Student
Medical Authorization *
By entering my full name below, I authorize Lindell staff to seek medical assistance for Student should the need arise.
Transportation Authorization *
By checking below, I give permission for student to ride with a Lindell staff member and/or an upperclassman student to, during and from a Lindell sponsored activity. (CHECK ALL THAT APPLY).
Photo Authorization *
By entering my full name below, I authorize any photography that includes Student to be used for the purpose of promoting Lindell programs. I understand that such photography remains property of Lindell Study Center
Parent/Guardian Signature *
By entering my name below, I understand that I am signing as a parent or legal guardian of the Student. I release the staff of Lindell Study Center (Lindell) from any liability that may result from the Student participating in a Lindell activity (or in transportation to/from/during it). I acknowledge the risk of injury and/or illness, including COVID-19, from participation in in-person activities is significant, including the potential for serious illness, injury, or death; and while particular rules, use of protective equipment, use of cleaning procedures, and personal control may reduce this risk, the risk of serious illness/injury or death cannot be eliminated. I knowingly and freely assume all such risks related to COVID-19 and protective measures against COVID-19, both known and unknown, on behalf of Student and myself, even if such risks arise from the negligent or allegedly negligent conduct of Lindell staff or other participants. I agree that Student will not attend activity if she is experiencing any symptoms of COVID-19 and acknowledge that Student will be sent home from activity if she displays any symptoms of COVID-19. I agree that Student will not attend the activity if she has been in close contact with someone with COVID-19 in the previous 14 days. I agree that by signing this Acknowledgement of Risks and Release of Liability, I, on behalf of Student, myself, and my heirs, agents, and assigns, hereby agree to waive, release, indemnify, hold harmless, and covenant not to sue Lindell, its Board of Directors, employees, agents, representatives, volunteers, insurers, assigns and successors, with respect to any and all claims, charges, and causes of actions, whether known or unknown, past, present or future, including, but not limited to, any and all costs, expenses, and attorneys’ fees, by reason of any injury, illness, death, damage, or loss [due to COVID-19 and protective measures against COVID-19], whether caused by negligence or for any other reason, arising out of, in connection with, or in any manner related to Student’s participation in Lindell activities. I represent that I, as parent/guardian with legal responsibility for the above-named Student, am fully competent to enter into this Acknowledgement of Risks and Release of Liability; and that I, for myself, my heirs, my assigns, and next of kin, and any other parent or guardian of Student, have carefully read this waiver and fully understand its contents and entered into this Acknowledgement and Release voluntarily and knowingly with an understanding of its ramifications. This Acknowledgment and Release is complete and signed of my own free will. I further certify that I have the legal authority to sign on behalf of myself, my student, and my family.
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy