Cocoa & Kindness Internship Acceptance Confirmation

Internship confirmation

Step 1 of 3

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How did you hear about this program?

Attended Inside Out Club in the past

Facebook or Instagram

Friends or family

Inside Out Club emails

Student's school /District

Other

Expectations to Ensure a Great Experience For All(Required)

Students and families must agree to the following expectations - treat everyone with respect at all times, 100% attendance unless you are sick and let the leader know ahead of time, and be on time to each meeting.

We have read the expectations and agree to follow them and we understand the possible consequences if I break the rules

Adult Name(Required)

First Last

Relationship to Student(s)(Required)

Email(Required)

Phone(Required)

Phone Type(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Additional Adult(Required)

Would you like to add an additional adult to serve as an emergency contact in case you are unable to be reached? This adult may also pick up your student(s).

Yes

Additional Parent or Guardian

Adult Name(Required)

First Last

Relationship to Student(s)(Required)

Email(Required)

Phone(Required)

Phone Type(Required)

Transportation(Required)

I confirm that myself or the other adult entered above with pick up my student(s) promptly

My student will drive themselves

My student will drive and/or I will pick them up depending on the day

Student(s) Information

Unpaid Internship(Required)

I acknowledge that this is an unpaid internship focused on building the 10 Skills that benefit my growth and future. I understand that I will also be completing tasks for Inside Out Club that would otherwise be handled by volunteers.

I confirm that this is an unpaid internship benefiting my personal growth

Please Note: If someone other than the adult(s) registered via this form today will be picking up your student from the workshop, please email their name and phone number to marion@insideoutclub.org.

Student #1's Name(Required)

First Last

Nickname

Gender(Required)

Race(Required)

Student's School Email(Required)

Cell Phone(Required)

If your student has a cell phone, please enter that number here. If not, please leave blank.

Text Messages

We send text reminders during the program and will send survey links periodically to measure long-term impact. If you are NOT ok with this, please click the circle below.

Please don't text my student

T-Shirt Size(Required)

All sized are unisex style.

Adult X-Small

Adult Small

Adult Medium

Adult Large

Adult X-Large

Grade(Required)

High school grade entering for the upcoming school year.

Child's High School Graduation Year(Required)

Example: 2029

Student's School(Required)

Please type the full school name of the high school this student attends during the school year.

School District(Required)

Write the full name of the school district.

Medical Information

Please include medical or allergy information we need to be aware of.

Snacks(Required)

Please send your child with a nut-free snack and water bottle. The leader will have some extra nut-free snacks in case your student forgets. If there are special concerns please include them in the student's medical section.

I have read and understand the above statement regarding snacks

Terms of Participation & Release of Liability

Language Selection(Required)

Please select the language to read the Terms and Conditions below / Seleccione el idioma para leer los Términos y condiciones a continuación / 請選擇閱讀以下條款和條件的語言

T&C's, Liability Release & Waivers(Required)

General Waiver & Release.

I, the undersigned, hereby certify that I am the parent or legal guardian of the below named Student and I have read and understand the above statements and agree to the terms and stipulations. I hereby grant my consent for the Student to participate in I Support Community NFP d/b/a Inside Out Club DuPage. I do hereby release and forever discharge I Support Community NFP d/b/a Inside Out Club DuPage, their agents, employees, volunteers, board members, and assigns, and their respective personal representatives, administrators, executors, and heirs, and any and all persons who might be claimed to be liable, whether or not herein named, (collectively, the “Releasees”), from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, (including but not limited to attorney’s fees, litigation expenses, and court costs) which I now have or may hereafter have, arising out of or in any way relating to any and all injuries, losses, and damages of any and every kind, to both person and property, and also any and all injuries, losses, and damages that may develop in the future, as a result of or in any way relating to participating in the Inside Out Club.

I further agree to indemnify and hold harmless Releasees from liability for the injury or death of any person(s) and damage to property that may result from Student’s negligent or intentional act or omission while participating in I Support Community NFP d/b/a Inside Out Club DuPage. I further agree that this Release shall be construed in accordance with the laws of the State of Illinois. If any term or provision of this Release shall be held illegal, unenforceable, or in conflict with any law governing this Release the validity of the remaining portions shall not be affected thereby. I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof and intend this to be legally binding.

Evaluation Release.

I Support Community NFP d/b/a Inside Out Club DuPage (IOCD) is continually working to improve the Inside Out Club. To do this they collect general, nondescript information of the child(ren)’s experience. No children will be identified by name. During Inside Out Club Live, your son/daughter will be asked to complete brief digital polls, which will ask them to share/rate their experience and identify items they learned, and upon completion, they will also be asked to draw a picture of what they learned. These activities are short and will not include your child’s name or identifying information. Your signature below indicates your consent for your child to be included in the evaluation.

I have read and agree to the T&C's, Release & Waivers

Términos y condiciones, exención de responsabilidad y exenciones(Required)

Renuncia y exención general .

Yo, el abajo firmante, por la presente certifico que soy el padre o tutor legal del Estudiante nombrado a continuación y he leído y entendido las declaraciones anteriores y estoy de acuerdo con los términos y estipulaciones. Por la presente otorgo mi consentimiento para que el Estudiante participe en I Support Community NFP d / b / a Inside Out Club DuPage. Por la presente libero y descargo para siempre I Support Community NFP d / b / a Inside Out Club DuPage, sus agentes, empleados, voluntarios, miembros de la junta y cesionarios, y sus respectivos representantes personales, administradores, ejecutores y herederos, y cualquier todas las personas que puedan ser consideradas responsables, ya sea que se mencionen en este documento o no, (colectivamente, los "Exonerados"), de todos y cada uno de los reclamos, demandas, daños, acciones, causas de acción o juicios de cualquier tipo o naturaleza, ( incluidos, entre otros, honorarios de abogados, gastos de litigio y costas judiciales) que ahora tengo o puedo tener en el futuro, que surjan de o de alguna manera se relacionen con todas y cada una de las lesiones, pérdidas y daños de cualquier tipo, tanto para persona y propiedad, y también todas y cada una de las lesiones, pérdidas y daños que puedan desarrollarse en el futuro, como resultado o de alguna manera relacionados con la participación en el Inside Out Club.

Además, acepto indemnizar y eximir de responsabilidad a los exonerados de responsabilidad por las lesiones o la muerte de cualquier persona y los daños a la propiedad que puedan resultar del acto u omisión negligente o intencional del estudiante mientras participa en I Support Community NFP d / b / a Inside Fuera Club DuPage. Además, acepto que este comunicado se interpretará de acuerdo con las leyes del estado de Illinois. Si cualquier término o disposición de este comunicado se considera ilegal, inaplicable o en conflicto con cualquier ley que rija este comunicado, la validez de las porciones restantes no se verá afectada por ello. Por la presente certifico y declaro que he leído lo anterior y comprendo completamente su significado y efecto y que tengo la intención de que sea legalmente vinculante.

Versión de evaluación .

I Support Community NFP d / b / a Inside Out Club DuPage (IOCD) trabaja continuamente para mejorar Inside Out Club. Para hacer esto, recopilan información general y anodina de la experiencia del niño (s). No se identificará a ningún niño por su nombre. Durante Inside Out Club Live, se le pedirá a su hijo / a que complete breves encuestas digitales, en las que se les pedirá que compartan / califiquen su experiencia e identifiquen los elementos que aprendieron, y al finalizar, también se les pedirá que hagan un dibujo de lo que ellos aprendieron. Estas actividades son breves y no incluirán el nombre ni la información de identificación de su hijo. Su firma a continuación indica su consentimiento para que su hijo sea incluido en la evaluación.

He leído y acepto los Términos y condiciones, la exención y las exenciones.

条款和条件、责任免除和豁免(Required)

一般豁免和免责。

我，以下签名人，特此证明我是以下指定学生的父母或法定监护人，我已阅读并理解上述声明并同意条款和规定。我在此同意学生参加 I Support Community NFP d/b/a Inside Out Club DuPage。我特此发布并永远解除我支持社区 NFP d/b/a Inside Out Club DuPage、他们的代理人、员工、志愿者、董事会成员和受让人，以及他们各自的个人代表、管理人员、执行人和继承人，以及任何和所有可能被声称对任何类型或性质的任何和所有索赔、要求、损害、诉讼、诉讼因由或诉讼负责的人，无论是否在此处指定，（统称为“被释放人”），（包括但不限于律师费、诉讼费用和法庭费用），我现在拥有或以后可能拥有的，由任何和所有伤害、损失和损害引起的或以任何方式与之相关，对双方人员和财产，以及未来可能因参加 Inside Out 俱乐部而导致或以任何方式发生的任何和所有伤害、损失和损害。

本人进一步同意对因学生在参加 I Support Community NFP d/b/a Inside 时的疏忽或故意行为或疏忽而造成的任何人的伤害或死亡以及财产损失而对免责人进行赔偿并使其免受伤害出俱乐部杜佩奇。我进一步同意，本免责声明应根据伊利诺伊州的法律进行解释。如果本发布的任何条款或规定被认定为非法、不可执行或与管辖本发布的任何法律相冲突，则其余部分的有效性不受影响。我特此证明并声明我已阅读上述内容并完全理解其含义和效果，并打算将其具有法律约束力。

评估发布。

我支持社区 NFP d/b/a Inside Out Club DuPage (IOCD) 不断努力改进 Inside Out 俱乐部。为此，他们收集了儿童经历的一般性、非描述性信息。不会通过姓名识别儿童。在 Inside Out Club Live 期间，您的儿子/女儿将被要求完成简短的数字民意调查，这将要求他们分享/评价他们的经验并确定他们学到的项目，完成后，他们还将被要求绘制一张图他们学到了。这些活动很短，不会包括您孩子的姓名或身份信息。您在下面的签名表示您同意您的孩子参与评估。

我已阅读并同意条款和条件、免责条款和豁免

Video & Photo Release

Photo & Video Release(Required)

Photo & Video Release.

I hereby expressly grant to I Support Community NFP d/b/a Inside Out Club DuPage (IOCD) and its employees, agents and assigns, the right to photograph my child(ren) and use those picture(s)/videography in connection with the promotion of IOCD and its programs. Means of promotion may include, but not limited to, the IOCD website, flyers or brochures, Facebook, Twitter, blog, LinkedIn and any other social media deemed necessary by IOCD.

I grant permission

I do not grant permission

Términos y condiciones de fotos y videos(Required)

Lanzamiento de fotos y videos .

Por la presente otorgo expresamente a I Support Community NFP d / b / a Inside Out Club DuPage (IOCD) y sus empleados, agentes y cesionarios, el derecho a fotografiar a mis hijos y usar esas imágenes / videografías en relación con la promoción de IOCD y sus programas. Los medios de promoción pueden incluir, entre otros, el sitio web de la IOCD, volantes o folletos, Facebook, Twitter, blog, LinkedIn y cualquier otra red social que la IOCD considere necesaria.

Doy permiso

No doy permiso

照片和视频条款和条件(Required)

照片和视频发布。

我在此明确授予我支持社区 NFP d/b/a Inside Out Club DuPage (IOCD) 及其员工、代理人和受让人的权利，为我的孩子拍照并将这些照片/录像用于与促进 IOCD 及其计划。宣传手段可能包括但不限于 IOCD 网站、传单或小册子、Facebook、Twitter、博客、LinkedIn 和 IOCD 认为必要的任何其他社交媒体。

我授予许可

我不授予许可

COVID-19 Guidelines

COVID-19 Guidelines(Required)

I have reviewed Inside Out Club DuPage's Covid-19 Safety Measures policy at https://www.insideoutclub.org/covid19 and agree to adhere to those guidelines. I acknowledge that the guidelines can change between registration and the event and that it is my responsibility to review and comply with the guidelines in place during the event and or program.

I have read and agree to the COVID-19 Guidelines

Directrices COVID-19(Required)

He revisado la política de medidas de seguridad Covid-19 de Inside Out Club DuPage en https://www.insideoutclub.org/covid19 y acepta adherirse a esas pautas. Reconozco que las pautas pueden cambiar entre el registro y el evento y que es mi responsabilidad revisar y cumplir con las pautas vigentes durante el evento o el programa.

He leído y acepto las Directrices COVID-19

COVID-19 指南(Required)

我已在 https://www.insideoutclub.org/covid19< 查看了 Inside Out Club DuPage 的 Covid-19 安全措施政策并同意遵守这些准则。我承认准则可能会在注册和活动之间发生变化，我有责任审查并遵守活动和/或计划期间制定的准则。

我已阅读并同意 COVID-19 指南