Dark Matter: A Writing Workshop for BIPOC Youth Parental Consent and Release Form

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Dark Matter: A Writing Workshop for BIPOC Youth Parental Consent and Release Form

Dark Matter: A Writing Workshop for BIPOC Youth Inspired by “The Impact of Images: Mamie Till’s Courage from Tragedy” with Lydia Theon Ware i

When: Three consecutive Sundays, February 11, 18, and 25, 2024, 1:30-3:00 PM

Where: Barbara and Art Culver Center for the Arts, 3824 Main Street, Riverside 92501

FREE for BIPOC teens ages 14-18, with parental approval.

What: BIPOC teens ages 14-18 are invited to a writing workshop based on the exhibition “The Impact of Images: Mamie Till’s Courage from Tragedy,” which runs through March 30, 2024 at the Culver Center of the Arts in downtown Riverside. This powerful collection of photographs includes both family photos and extraordinary images made by Black photojournalists, and will inspire writing, reflection, and insight for a new generation.

Completion of this Consent and Release form is required for participation in this arts program offered by Inlandia Institute (hereinafter referred to as "the Program").

Se requiere completar este formulario de autorización y permiso de los padres para la participación en este programa de arte ofrecido por el Instituto Inlandia (referido "el Programa" en lo sucesivo).

Please complete one form per participating teen. / Favor de completar un formulario por cada adolescente participante.

Email *

I certify that I am the parent or guardian of the participant named in this form, or I certify that I am 18 years of age:

Certifico que yo soy el padre o guardián del participante nombrado en este formulario, O bien, certifico que tengo 18 años de edad:

Participant's first name / Nombre del participante
*

Participant's last name / Apellido del participante
*

Participant's age

Edad del participante

Your email address

Su dirección de correo electrónico

Parent, guardian, or emergency contact phone number

Número de teléfono de contacto del padre, guardián, o contacto de emergencia

Your contact phone number

Su número de teléfono de contacto

Supervision and Safety: Trained staff and volunteers will supervise the Program to ensure the safety and well-being of all participants. Reasonable precautions will be taken to minimize risks and prevent accidents. However, I understand that accidents may still occur despite these efforts. In case of an emergency, I authorize the Inlandia program staff to seek necessary medical treatment for the participant. I will be responsible for any associated medical expenses.

Supervisión y seguridad: El personal capacitado y los voluntarios supervisarán el programa para garantizar la seguridad y el bienestar de todos los participantes. Se tomarán las precauciones razonables para minimizar los riesgos y prevenir accidentes. Sin embargo, entiendo que aún pueden ocurrir accidentes a pesar de estos esfuerzos. En caso de emergencia, autorizo al personal del programa Inlandia a buscar el tratamiento médico necesario para el participante. Seré responsable de cualquier gasto médico asociado.

Yes, I authorize and agree to the above / Sí, autorizo y acepto lo anterior.

Consent to Photograph and Video: I grant permission to Inlandia and its representatives to photograph and/or video record the participant during the Program for promotional purposes, including but not limited to brochures, websites, and social media platforms. I understand that the participant's identity will not be disclosed without obtaining separate consent.

Consentimiento para fotografía y video: Otorgo permiso a Inlandia y sus representantes para fotografiar y/o grabar en video el participante durante el Programa con fines promocionales, incluidos, entre otros, folletos, sitios web y plataformas de redes sociales. Entiendo que la identidad de participante no se divulgará sin obtener un consentimiento por separado.

Yes, I authorize and agree to the above / Sí, autorizo y acepto lo anterior.

I hereby voluntarily release, forever discharge Inlandia Institute and UCR Arts, its officers, directors, employees, volunteers, and agents from any and all claims, demands, or causes of action, which are connected with participation in the Program or the use of the facilities.

I agree to pay for any and all medical expenses incurred and give permission to the doctor or health care professional to provide medical care if necessary.

The information I've given in this form is complete and accurate. By signing this form, I confirm that I have fully informed myself of the contents of this Consent and Release Form by reading it before I signed it. I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this document with binding legal effect.

Por la presente libero voluntariamente, libero para siempre al Instituto Inlandia y UCR Arts, sus funcionarios, directores, empleados, voluntarios y agentes de cualquier reclamo, demanda o causa de acción que esté relacionada con la participación en el Programa o el uso de las instalaciones.

Acepto pagar todos y cada uno de los gastos médicos incurridos y doy permiso al médico o al profesional de la salud para brindar atención médica si es necesario.

La información que he proporcionado en este formulario es completa y precisa. Al firmar este formulario, confirmo que me he informado completamente sobre el contenido de este Formulario de Autorización y Consentimiento al leerlo antes de firmarlo. Garantizo que poseo todos los derechos, poderes y privilegios de un padre o guardián legal necesarios para ejecutar este documento con efecto legal vinculante.

Yes, I authorize and agree to the above / Sí, autorizo y acepto lo anterior.

Contact Information: I will promptly notify the Program staff of any changes to my contact information provided in this consent form.

Información de contacto: Notificaré de inmediato al personal del Programa sobre cualquier cambio en mi información de contacto proporcionada en este formulario de consentimiento.

Yes / Sí

I, the undersigned, hereby give my consent for the above named participant to participate in the Program and understand and agree to the terms and conditions as set forth in this Consent and Release form:

Yo, el abajo firmante, por la presente doy mi consentimiento para que el participante mencionado anteriormente participe en el Programa y comprenda y acepte los términos y condiciones establecidos en este formulario de consentimiento y autorización:

Yes / Sí

Your typed name signifies your written consent

Su nombre mecanografiado significa su consentimiento por escrito

A copy of your responses will be emailed to the address you provided.

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