Certification and Consent:
I hereby certify that the information on this form is complete and correct to the best of my knowledge. I consent to have this information entered and saved into the LifeBridge Community Services confidential client database. I understand that client records are confidential and are not released or shared with anyone outside of LifeBridge Community Services without the parent/guardian’s written consent except as required by law.
I have read the Urban Scholars Program responsibilities and both my Scholar and I agree to meet those expectations.
I give my permission for my child to be photographed, recorded, and/or videotaped by LifeBridge Community Services during agency-sponsored activities. I also understand that these photos, audio, and/or videotapes may be used in future publications, as marketing material or as training material.
I understand that LifeBridge Community Services is operating the Urban Scholars Program with great care, but that COVID-19 is a transmittable disease and my child is only in LifeBridge’s care during the daytime program. I cannot hold LifeBridge Community Services liable if my child contracts COVID-19 or any other transmissible illness.
I give my permission for (Scholar’s name) to attend the Urban Scholars Summer Program at LifeBridge Community Services and to participate in all activities, subject to the authority of the Urban Scholars Program Director.