One-time Release Form for 2019-2020 September-June RYC Middle School Grandfriend Programs
Hello! This release form provides necessary permissions and emergency information for any and all of the Rye Youth Council Grandfriend Programs from September 2019 through June 2020. Sign ups will be distributed each month -- but you will only have to fill this online form out once.

Form For Rye Youth Council (RYC) Make a Grandfriend Program at The Osborn Retirement Community

2019-20 Dates: September 23, October 7, November 4, December 16, January 6, February 3, March 9, April 20, May 4, June 8th

Time: 2:340-4 pm
Place: Meet at the front of Rye Middle School and a bus will take the kids to The Osborn, 101 Theall Road, Rye, NY 10580. Participants should be picked up at The Osborn at 4pm.
Who: Middle school aged students who live or attend schools in Rye and Rye Neck, and who would like to make meaningful connections to senior citizens.

I, the undersigned, certify that I am the parent or legal guardian of the Rye Youth Council child-participant and do hereby give my consent for the child-participant to attend the Make a Grandfriend program on and of the dates listed above. I understand and agree that my child will be chaperoned by an adult Rye Youth Council Party.

"Rye Youth Council Parties" include RYC and its successors, officers, members, directors, volunteers, employees, and agents.

I hereby covenant and agree to release and hold harmless the Rye Youth Council Parties and The Osborn from and against any and all liability, loss, damages, claims, or actions (including costs and attorney fees) for bodily injury and/or property damages, to the extend permissible by law, arising out of participating in this field trip.

I agree to indemnify and hold harmless the RYC Parties for any loss, cost, or damage caused by the undersigned participant during his or her participation in RYC events. I will assume the costs from damage caused by me or my undersigned child-participant at any RYC event.
Email address - of the undersigning parent or legal guardian *
Your answer
Home Address of the participant *
Your answer
While I indemnify and hold harmless the RYC Parties for personal injury, sickness or death, which may be incurred by the participant to the fullest extent permitted by law, while I am aware that RYC Parties will not monitor the child-participant’s medical needs at RYC events, and while I am aware that the following information may not be available to RYC Parties at events, I would like RYC administrators to know this about my child’s allergies and other medical requirements, in case of emergency:
Your answer
My child has permission to carry and to take the following medications, without supervision at RYC events:
Your answer
If the participant is under 18 years of age, a custodial parent or legal guardian must sign. The undersigned(s) represent(s) it/they has/have authority to sign under these conditions.
Your answer
I give RYC Parties permission to photograph and use pictures and videos of the undersigned participants for any purpose deemed necessary by RYC, including, but not limited to, website posts, newsletters, news reports of various media, fundraising activities and advertising - online and in print - for RYC programs. I understand that the participants names will not be used for any of these purposes. *
Student Participant's Name *
Your answer
Student Participant's Age *
Your answer
Student Participant's Grade *
Name of Parent/Legal Guardian *
Your answer
Parent/Legal Guardian Contact # *
Your answer
Emergency Contact Name and Number *
Your answer
My child's physician is (Name, address, phone) *
Your answer
I have read the entire statement above and I agree that it is true. (Please initial) *
Your answer
Date *
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