ALLEGHENY INTERMEDIATE UNIT APPRENTICESHIP PROGRAM STUDENT PARTICIPANT -- RELEASE AND WAIVER The undersigned, while participating in the

Allegheny Intermediate Unit Gifted & Talented Education Apprenticeship Program, agrees to abide by all rules and safety requirements for the site to be visited, and assumes all risks arising from or related to his or her participating in the program. The undersigned, and any parent or guardian, if a minor, hereby waives and releases the Allegheny Intermediate Unit from any and all claims and causes of action against the aforementioned for any damage or injury to the person or property of the undersigned, or parent or guardian, alleged to have been caused by any act. This release and waiver shall apply at all times that the undersigned is away from his or her residence for the purpose of participating in the Allegheny Intermediate Unit Apprenticeship Program. Date: If a minor, also signed by: (Parent or Guardian) Signed by:

EMERGENCY INFORMATION PLEASE PRINT Name School School Contact and Phone Number Emergency Contact & Phone Number

PLEASE LIST ANY SPECIAL NEEDS RELATIVE TO PHYSICAL CAPABILITIES, DIETARY RESTRICTIONS OR TAKING MEDICATIONS THAT YOU MAY HAVE:

Please provide an updated e-mail address that can be used to contact students with important information regarding the Apprenticeship. E-MAIL ADDRESS:

(please print)

it will be deemed you choose "no credit. then I would like the following credit to be used: Credit Name (You may use your name.Print Form Allegheny Intermediate Unit Photograph Release Form I. If no choice is indicated by you. Parent's Signature: Date: . I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. then the signature of that student's parent or legal guardian is also required. I also understand that the Allegheny Intermediate Unit's display of photographs of me on the Internet and/or in other displays and/or in the news media will allow the photographs to be viewed by the general public. or indicate "no credit" if you do not want your name used at all. I understand and consent that photographs of me may be electronically displayed by the Allegheny Intermediate Unit or by the news media. _________________________ (print name). hereby grant to the Allegheny Intermediate Unit permission to display and share electronically via the Internet and/or in other displays and/or in the news media photographs of me taken in conjunction with my participation in: Event Name By signing this release. Full Name: Home Address: State: School District: District Address: State: Phone: (H) Student’s Date of Birth: Student's Signature: (W) E-Mail Address: Date: Zip: Zip: If this release is obtained from a student under the age of eighteen (18).") By signing this form. initials or a combination thereof. If any of the above-listed works and/or materials are displayed on the Internet by the Allegheny Intermediate Unit and/or used in other informational displays.

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