Student Applicant Name:

School Name & Location:

Parent/Guardian Name:

Parent/Guardian Email Address:

Parent/Guardian Address:

Best phone to reach you:

Next best phone to reach you:

Alternate Emergency Contact (not parent or guardian):

Name:

Best phone to reach you:

Relation to Applicant:

Next best phone to reach you:

PERMISSION TO PARTICIPATE

I affirm that I am a parent/guardian of the above-named student applicant. YesNo

I grant permission for my student applicant to participate in this year's Indigenous Youth Gathering organized by WISE NL. YesNo

Your Name:

Date:

I authorize WISE NL to use:

• Photographs (both individual and group) in which my child may be identified by name.

• Sound recordings of my child

• Interviews of my child

• Printed material written by my child

For use in:

• Promotional initiatives such as website, reports and other WISE NL programs and brochures
  for WISE NL and Memorial University of Newfoundland.

• Media releases such as paper, newsletters, magazines, etc.

I agree not to hold WISE NL responsible for the content of such photographs, sound recordings or interviews or the specific use to which they may be applied. I understand I have the right to refuse to grant this authorization now or to revoke authorization at any time. Compliance is voluntary. Consent remains valid until withdrawn.

By clicking the "Yes" box below, you agree to the above conditions regarding image and recording release.
Yes, I give consent.No, I do not give consent

Your Name:

Date: