Student Membership & Permissions Form

Page 1

Student Contact Information

First Name

Last Name

High School

Other School(s)

Grade

Student Email

Student Phone

Student Birthdate

Check this box to join Leaders in Training

buildOn’s Leaders In Training (L.I.T.) program teaches you how to lead service in your school and community. Meetings are 2 hours every other week, and L.I.T. students are required to participate in a Digital Partnership Program (making you eligible to receive a tablet).

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Parent/Guardian Email

How did you hear about buildOn?

Which Social Media Platforms?

Other

Can you share the names you know for any of the following: buildOn Staff, School Staff or a Friend?

Student Permission: Please read and accept the terms on the next page

Date

Digital Student Engagement Form Complete

Permission Slip:

PERMISSION AND RELEASE FORM

Permission Slip:

Dear Student,

Please read the permission, release and disclaimer statements below. If you agree, please indicate your consent by filling in your name and providing the information requested below, and then submit this completed form online using the submit tab below.

Permission and Release:

As a preliminary matter, whenever the word "we" is used below, it is understood that such use means and refers to both the student and his or her parents or legal guardians. The use of the words "I", "me" or "my" shall mean and refer to the student and, where applicable, shall mean the permission and consent of the student alone if he or she can legally consent for themselves.

I would like to participate in the Digital Media Events described on the Previous Page and I or we, as applicable, hereby give permission and consent to such participation, including my participation in all planning and other activities related to the Digital Media Events. buildOn has my consent and permission to obtain my student identification numbers, birthdate, full legal name, current grade, school transcript, a record of my attendance, and my post-graduate plans, directly from my school as part of my participation.

I or we, as applicable, also give permission and consent to the use of my statements and quotes, and the use of photographs, images or audio or video recordings of me, taken, recorded, or screenshot during any of the Digital Media Events. I or we, as applicable, grant and give to buildOn (and its assigns, licensees and designees) the right to use the same (“My Likeness”), for promotional, marketing, publicity or other lawful purpose without any compensation. This grant and right is irrevocable and includes the use of My Likeness in print, on the Internet, on all digital and social media platforms, and all other forms of media now known or later created.

Release:

I or we, as applicable, release and hold harmless buildOn, its officers, directors, employees, agents, volunteers, sponsors, company partners, successors and assigns, and the State Board of Education (and its members, officers, employees, and agents), from any and all claims, causes of action, liabilities, costs, expenses, or damages of any kind whatsoever, that I or we, as applicable, may have relating to my participation in any of the Digital Media Events.

Other Terms:

This Permission and Release shall remain in place until terminated in writing by me or by any one of my parents or guardians (if applicable), and shall apply to all Digital Media Events that I may participate in from time to time prior to the effective date of any such written termination. Any written termination shall be properly sent to info@buildon.org.

Contact Information