West Oakland Legacy & Leadership Project Application 2018-2019
THE WEST OAKLAND LEGACY & LEADERSHIP PROJECT (WOLLP) invites students to be inspired, empowered and expressive through environmental awareness and visual art. Each student in our program will also earn a stipend and receive the necessary guidance, support and team effort required to graduate high school.

Students in our WOLLP Program will engage in 30 weeks of after school programming lead by AHC Artesteem and our partners, City Slicker Farms and the West Oakland Environmental Indicators Project. WOLLP students will work with and learn from Professional Artists, Advocates and Agriculturalists while engaging in activities promoting environmental awareness, empowerment and community advocacy.

AFTER WE RECEIVE YOUR STUDENTS ENROLLMENT APPLICATION, our program manager may contact you to document additional information so we can complete the enrollment process. The additional information needed will include: emergency contacts, pick up / release information (if applicable), and your students medical information (allergies, physical limitations, dietary restrictions, etc...).

IN ADDITION TO THIS APPLICATION FORM, we will require all Parents / Guardians to review and agree to our program terms, conditions, and policies which include: liability release, photo release, artwork license, and criteria for exhibitions and art sales. We will ask for your dated signature on a separate form which can be signed in-person or mailed to the AHC Office.

TO MAIL IN OR DROP OFF YOUR APPLICATION, you can find a full .pdf version by visiting this link: http://bit.ly/2cga87I. Please print and fill out your form, and mail or drop it off by NO LATER THAN AUGUST 1st 2018 to the following address:

Attitudinal Healing Connection, Inc.
Attn: WOLLP Application Form
1980 Mandela Pkwy
Oakland, CA 94607


Student Information
Student's School *
Your answer
Primary Teacher *
Your answer
Grade Level *
Grade Point Average
Your answer
Students Name (First, Middle, Last) *
Your answer
Birth Date (MM/DD/YYYY) *
Your answer
Address (Number, Street, Apt. #, City, Zip) *
Your answer
Students Medical Information
Doctors Name *
Your answer
Clinic / Office Phone *
Your answer
Medical Insurance Carrier *
Your answer
Policy # *
Your answer
Please explain medical or special needs: (Allergies, Physical Limitations, Medications, Dietary Restrictions). *
Your answer
Family Household Information
Parent / Guardian Name *
Your answer
Relationship to Student (Mother / Father / Guardian) *
Your answer
Address *
Home Phone *
Your answer
Work Phone *
Your answer
Cell Phone *
Your answer
Email Address *
Your answer
Emergency Contact Information
If possible, please provide 2 emergency contacts for your student.
Name *
Your answer
Relationship *
Your answer
Phone *
Your answer
Alternate Phone
Your answer
Your answer
Your answer
Your answer
Alternate Phone
Your answer
Liability Release
As a condition of and in consideration for the opportunity to participate in activities offered, organized, sponsored, and/or
hosted by Attitudinal Healing Connection, Inc. (“AHC”), I hereby release and hold harmless AHC, its officers, directors,
employees, volunteers, and all other persons acting on its behalf, from any and all claims, causes of action, liability, damages, loss, and expense, including attorneys’ fees and court costs, whether based upon theories of strict liability or negligence, gross or otherwise, in connection with participation by me and/or my child(ren) in any activity conducted by AHC, whether on its premises or elsewhere. I make this release in all my legal capacities, including on my own behalf, on behalf of my spouse and any other parent or guardian of the enrollee(s), and as legal representative and guardian of the enrollee(s).

I understand and agree that this Release is intended to be as broad and inclusive as is permitted by the laws of the State of California. I further agree that, if any portion of this Agreement is held invalid, the remaining portions shall remain and continue in full force and effect. I understand that this is a full and final release applying to all unknown and unanticipated damages arising in connection with my participation in AHC, as well as to those now known or disclosed, and I waive all rights and benefits that I now possess or in the future may acquire under the terms of Section 1542 of the Civil Code of the State of California, which provides: “A general release does not extend to the claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.”

Photo Release
I hereby grant permission to the Attitudinal Healing Connection, Inc. (AHC) and its partners/affiliates to use my child’s
image/voice on its online website or in other official Attitudinal Healing Connection, Inc. publications without further
consideration, and I acknowledge Attitudinal Healing Connection, Inc.’s right to crop or treat the image/voice at its discretion.

I also acknowledge that Attitudinal Healing Connection, Inc. may choose not to use my image/voice at this time, but may do so at its own discretion at a later date. I also understand that once my image/voice is posted on Attitudinal Healing Connection Inc.’s website, the image/voice can be downloaded by any computer user on or off site.

Therefore, I agree to indemnify, release and hold harmless from any claims All Employees and Board of Directors of Attitudinal Healing Connection, Inc. In addition, Attitudinal Healing Connection, Inc. reserves the right to discontinue use of image/voice without notice.

Artwork License
In my capacity as legal representative and guardian of my child(ren), I hereby grant to Attitudinal Healing Connection, Inc. (“AHC”) a perpetual, nonexclusive license (“License”) to reproduce, publish, or otherwise make use of any and all works of art created by my child(ren) during participation in any activity conducted by AHC, whether on its premises or elsewhere (the “Artwork”).

Such uses include, but are not limited to, publication of the Artwork in promotional or other materials produced by AHC, publication of the Artwork electronically on AHC’s online website or on other websites maintained by organizations or institutions with which AHC has entered into agreements (such as educational institutions and community organizations), and reproduction of the Artwork for display at premises owned or operated by AHC.

I understand and agree that AHC’s enrollment of my child(ren) in activities conducted by AHC shall serve as the sole consideration to be provided by AHC for this License.

Criteria for Exhibitions and Art Sales
1. Agency; Purposes
The Parent/Guardian of the Student Artist appoints Attitudinal Healing Connection, Inc. (AHC) as agent for the works of art (“the Artworks”) consigned under this agreement, for the purposes of exhibition and sale. This agreement applies only to works consigned under this Agreement and does not make AHC a general agent for any other works.

2. Exclusive Representation
The Parent/Guardian of the Student Artist hereby appoints AHC as their sole representation throughout “the ArtEsteem Exhibit Event in 2019 and Traveling Exhibition 2019/2020” to sell or otherwise make available for acquisition to the public, the Student Artist’s Artworks.

3. Consignment and Duration of Consignment
The Parent/Guardian of the Student Artist hereby consigns to AHC, and AHC accepts on consignment, those artworks to be exhibited. The Parent/Guardian and AHC, will at a later date sign an Artwork Inventory Sheet of the Student Artist’s artwork to be exhibited and/or sold. The Parent/Guardian of the Student Artist and AHC agree that the initial term of consignment for the Artworks is to be from January 1, 2019 through June 31, 2019 and that the Parent/Guardian of the Student Artist and the Student Artist do not intend to request its return before the end of this term. Thereafter, consignment shall continue until the Parent/Guardian of the Student Artist and the Student Artist requests the return of any or all of the Artworks or AHC requests that the Parent/Guardian of the Student Artist take back any or all of the Artworks with which request the other party shall comply within 30 days. Note that some artwork may be used in traveling exhibits during and thereafter the consignment period.

4. Promotion
AHC will use its best efforts to promote the sale of the Artworks. AHC’s promotional expense will be factored into the retail price. AHC agrees to provide adequate display of the Artworks, and to undertake other promotional activities on AHC and the Student Artist’s behalf. AHC shall clearly identify all Artworks with the Student Artist name.

5. Pricing
AHC’s Commission; Student Artist Commission; Terms of Payment AHC shall set the selling price for Artworks listed on the Artwork Inventory Sheet, under this agreement. AHC and the Parent/Guardian of the Student Artist agree that AHC’s commission for the promotion and production of the traveling exhibit is 30% of the Retail Price of the Artwork; and AHC’s commission for the ArtEsteem Scholarship Fund is 20% of the Retail price of the Artwork. Payment in the amount of 50% of the Retail price of the Artwork shall be made to the Student Artist by AHC no later than 60 days after the sale. Parent/Guardian must accompany the Student Artist for payment distribution.

6. Criteria for artwork to be exhibited
a. The work must be well thought out, critiqued/reflected upon and completed.
b. The artwork must have a narrative component that makes a social, community or self-reflective statement.
c. The work can be a drawing, painting, print, sculpture, collage, or craft.
d. Students and their family must attend the exhibit and bring friends.

7. Financial literacy and art sale
a. Students should submit a price on their work. It is understood that work will be given a final price by the Attitudinal Healing Connection/ArtEsteem staff during the review, based on level of involvement with the subject and art material used.
b. Students should understand the business of art galleries (promotions, space, etc.).

8. Art Work Logistics
Students whose work did not sell will have it returned. Any work not picked up by May 31, 2015, may continue to be exhibited, sold or destroyed at the discretion of the Attitudinal Healing Connection, Inc.

Retention, Sale, Or Destruction Of Artwork
In my capacity as legal representative and guardian of my child(ren), I understand and agree that, during or at the conclusion of my child(ren)’s participation in any program(s) conducted by Attitudinal Healing Connection, Inc. (“AHC”), my child(ren) will have the opportunity to keep and take home any work(s) of art created during said program(s). I further understand and agree that any and all work(s) of art not kept or taken home by my child(ren) at the conclusion of participation in any AHC program: (1) will be considered abandoned; (2) will become the property of AHC; and (3) may thereafter be retained by AHC, sold by AHC, or destroyed, as AHC sees fit.

OFCY Release
The Oakland Fund for Children and Youth (OFCY) provides grants to many programs serving youth and their families in Oakland. As a parent and/or legal representative and guardian of your child, AHC hereby notifies you that all programs funded by OFCY are required to participate in an independent evaluation. Programs funded by OFCY are required to have all clients give OFCY permission to input their information into a database for purposes of evaluating program and fund performance. Every enrolled client (and their parent, guardian, or other legally authorized representative if a minor) must give consent to being evaluated by the City of Oakland and the designated evaluation consultant, including sharing information with and from Oakland Unified School District (if applicable).

As part of the evaluation, your child may be asked to complete a survey. The survey questions ask what children do in their program, how much they like what they do, and demographic information. The survey will take about 15 minutes to complete. Your child will only have to answer the questions to which they feel comfortable responding.

During your child’s participation in the OFCY-funded program, he/she may participate in an activity that is being photographed or videotaped; these photographs/video recordings may be used for promotional purposes.

Release of Information – Evaluation of Programs and Tracking of Progress
I give permission to enter my child’s information in a database and for the OFCY independent evaluators and program staff to review my child’s program data and school data (if applicable), monitor my child’s progress, and for my child to complete evaluation surveys for the purpose of determining program effectiveness.
Photo and Video Release
I authorize OFCY or any third party it has approved to photograph or videotape my child during the OFCY-funded program activities and to edit or use any photographs or recordings at the sole discretion of OFCY. I understand that I and my child shall have no legal right or interest arising from the recording, including economic interest. I also agree to release and hold harmless OFCY and any third party it has approved from and against all claims, demands, damages, and liabilities arising out of or use of the recording.

I agree to update the information I have provided in this application as necessary, providing AHC with the correct current information. I, the undersigned, agree to all terms, conditions, policies, and agreements stated above and the information I have provided is correct to the best of my knowledge.
Parent Guardian (Type Name) *
Your answer
Student (Type Name) *
Your answer
Date (MM/DD/YYYY) *
Your answer
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