SLIC Core Application

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    Contact Information

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    Emergency Contact Information

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    Reference

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    Applicant's Statement

    The information contained in this application is correct to the best of my knowledge. I authorize any references listed in this application to relay information they may have regarding my character. I release all such references from liability for any damage that may result from furnishing such evaluations to you, and I waive any right that I have to inspect references provided on my behalf. The facts contained in this application are true and complete. I understand any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to cancel further consideration of the application or immediately discharge me from Pathways, MI/ SLIC. Pledge To Be Drug Free I understand that as a SLIC Core member I am stating that I am committed to being a drug and alcohol free youth. I also understand that Pathways, MI/ SLIC takes this commitment very seriously, if found to not adhere to this pledge, I will be dismissed immediately from SLIC Core.
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    Indemnity and Waiver of Claim

    I hereby release Pathways, MI and their employees from liability for any injury my child may sustain. I fully assume all responsibility for injuries she/he may sustain while participating in program activities or while in travel to or from said activities and field trips. Pathways, MI is not responsible for lost, stolen or damaged property. I agree that Pathways shall not be responsible for my or my child’s lost, stolen or damaged property or medical expenses arising directly or indirectly out of my child’s participation in this program. I agree to hold Pathways harmless with respect lost, stolen or damaged property or medical expenses arising from my child’s participation and waive any and all claims against Pathways related to lost, stolen or damaged property or medical expenses arising from my child’s participation.
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    Photo Release Permission

    I understand SLIC participants are sometimes photographed or videotaped for use in promotional and educational materials including but not limited to the Public Service Announcements, news articles, promotional brochures, etc. I consent and give permission to you and those acting under your authority to publish, use and reproduce photographs/videos of my minor/child, in publications and media (www.pathwaysmi.org, www.ottawaslic.org, and www.facebook.com/ottawaslic.org , newspapers, television and the local DFC/SLIC flyers). I further consent to the use of the name and likeness of my child for these promotional purposes. I waive the opportunity and right to inspect or approve any use of the photographs/videos or any publication based on the photograph, or any use to which the article may be put. I release Pathways, MI and the SLIC Youth Coalition, their officers, directors, agents and employees and those acting under their authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the name and photograph or the taking and use of the likeness referred to above.
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