Participation Permission and Waiver
This form is REQUIRED to participate in She-EO, LLC programs - except Girl Scout programs.
Please complete ONE new form every year (or when your child's information changes).
This form does not take the place of forms required by our community partner or site host.
Your child can not participate until this form is completed, submitted and received by our office.
if you would prefer a PDF version of this form to complete and submit.
Submit a new form each year, not for each location.
YOUR PROGRAM LOCATION (camp, class or event)
FALLS CHURCH VA
PRINCE GEORGES MD
PRINCE WILLIAM VA
Participant's First and Last Name:
Mom's First and Last Name:
Mom's Home Phone Number:
Mom's Mobile Phone Number:
Dad's First and Last Name:
Dad's Home Phone Number:
Dad's Mobile Phone Number:
Dad's Email Address (if different):
Parent's Home Address: Street, City, State, Zip Code
Emergency Contact Person (not parent) Name and Phone Number
Person(s) authorized to pick up participating girl (other than parent):
Does the participant have any allergies (food, environment, etc)? Please list below
Does the participant have any special needs or abilities? (hearing aid, dyslexia, ADD, gifted, etc.) Please list below
What do you wish your daughter will get from attending a SheEO Academy program?
FINANCIAL LITERACY SURVEY
Does your daughter have a bank account? Check one.
If no, why not?
If yes, what type of account is it?
Savings and Checking
How often does she visit the bank?
Has your daughter earned money that was not a gift?
(1) I/we certify that the information on this form is accurate and up-to-date. (2) In case of an emergency, I/we give permission to She-EO, LLC (d.b.a. SheEO Academy) to give immediate attention and seek medical treatment for my daughter the participant. (3) I/we hold harmless She-EO, LLC and its agents or employees, for injuries occurring to my daughter whose name is mentioned in this form while participating in She-EO, LLC programs. TYPE YOUR FULL NAME to accept the terms above:
I grant permission to She-EO LLC (d.b.a SheEO Academy), and its agent or employees, to use photographs and images taken of (participant) while participating in programs sponsored by She-EO LLC. She-EO LLC agrees to take precautions to avoid misrepresentation of the girl’s image or messaging. These images may be used in publications, on displays boards and in electronic media. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph. I hereby agree to release and hold harmless She-EO LLC, and its agents or employees, including any firm hired to publish and/or distribute the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. I am the legal guardian of the above mentioned child. I have read this release before signing below, and I fully understand the contents, meaning, and impact of this release.
I DO GRANT PERMISSION
I DO NOT GRANT PERMISSION
TYPE YOUR FULL NAME to accept the terms above:
Date You Submit Your Form
THANK YOU from She-EO, LLC!
This information is for internal use only and will NOT be sold or shared with third parties without permission. Email
or call 866-697-4336 if you have any questions. Visit
for more information.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of She-EO LLC.