Debate Spaces Academy Registration
This permission form covers your child’s participation in the Debate Spaces Academy on March 30th and/or April 27th (at 20 Somerset St--Room 265) for a cost of $20 per day. To participate please fill out and submit our student application form below. If you have any questions regarding this application, please contact Tessa Holtzman at debatespacesboston@gmail.com. Thank you and we welcome you to the Debate Spaces Academy!
Email address *
Student Name (First, Last) *
Your answer
School Name *
Your answer
Current Grade *
Your answer
Gender
Ethnicity (optional)
Your answer
Any dietary restrictions we should be aware of? *
Your answer
Parent Name (First, Last) *
Your answer
Phone Number (Parent's) *
Your answer
Email Address (Parent's) *
Your answer
I do hereby consent that my child may participate in the stated activity, and in consideration for the Debate Spaces Academy giving its time and supervision of such activity, do hereby personally on behalf of my child, absolve and release Debate Spaces Academy, its agents and volunteers from any claim of personal injuries which might be sustained by my child while participating in such activities, or while returning to their home. *
The Debate Spaces Academy documents their programming using photography and video, as well as quotes from students, for documentation, fundraising, promotional, and evaluation purposes. Video footage, still images and quotes may appear on Debate Spaces Academy’s website as well as publicity, fundraising, and promotional materials. All video footage, still images and quotes used in public materials will appear without reference to the full names of specific students. By checking this box, I acknowledge that I am giving the staff of the Debate Spaces Academy and affiliates permission to videotape, photograph or interview me while I participate in Debate Spaces Academy activities. I understand that these quotes, photographs and video footage may appear in Debate Spaces Academy's publicity, outreach, or fundraising materials, which will be accessible to the public. I do not expect to receive any financial compensation in return for any footage/photographs/quotes, or for the display of the resulting images. *
Participation is completely voluntary. You have the right to terminate your child’s participation at anytime or refuse to participate entirely without jeopardy to your status in the program.
In order to assure that Debate Spaces Academy is of high quality and has a positive impact on your child(ren), Debate Spaces Academy engages in ongoing evaluation and quality improvement efforts. Therefore, your child may be asked to fill out surveys at the various times during the program. All data obtained from your child will be kept confidential and will be used by staff to increase the quality of the program. All data analyzed through this system will highlight combined or group results. Staff within Debate Spaces Academy will have access to the data so that they can continue to improve the program and support your child’s individual needs. *
Participation is completely voluntary. You have the right to terminate your child’s participation at anytime or refuse to participate entirely without jeopardy to your status in the program.
Please write your signature below indicating that you have read and understood the permission to participate, media consent, and survey consent. By signing your name, you are confirming your consent. (Last Name, First Name, Date) *
Your answer
Confirm that your child will arrive for the Academy at 10am on March 30th at Suffolk University (20 Somerset St--Room 265) and will be ready to depart when programming finishes at 3:30pm. *
Will your child be attending our second Debate Spaces Academy on Saturday, April 27th? *
Confirm that you have submitted payment ($20 per day) to: www.paypal.me/debatespaces. (Scholarships avaliable upon request, please email debatespacesboston@gmail.com for more information)
A copy of your responses will be emailed to the address you provided.
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