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Release of Urban
Life Training & Reality Assessment (ULTRA) Teen Choice, Inc. We/I the
undersigned, individually and as parent(s) of _________________________________,
who is a student of ____________________________
School, do hereby consent to our/my child's participation in the various
activities of Urban Life Training & Reality Assessment (ULTRA) Teen Choice
during the current school year. In
giving this consent, We/I acknowledge and realize that activities planned and/or
sponsored by ULTRA Teen Choice for the school year may include, by the way of
illustration, weekend activities, such as abstinence based conferences outside
of Washington, DC, bowling, ice skating, roller skating, cookouts, service
projects and recreational activities.
We/I consent to my child's participation in such activities or activities
similar to them and as appropriate and necessary, agree that my child can be
transported to and from such activities by organizers and volunteers of ULTRA
Teen Choice.
ULTRA
Teen Choice will make effort to ensure that all activities are safe. However, We/l realize that
there is the possibility that my child may be injured.
In consideration of the time and effort provided by ULTRA Teen Choice in
the planning, supervision, transportation, chaperoning, and administration of
programs and activities sponsored by ULTRA Teen Choice, We/l hereby release and
discharge the organizers and volunteer helpers of ULTRA Teen Choice, its agents,
employees, and officers from any and all claims, lawsuits, demands, or damages
which We/I might have (or which my heirs, executors, administrators or assigns
might have or claim to have) against ULTRA
Teen Choice for any and all personal injury or injuries to property caused by or
arising out of my child's participation in the afore described activities in the
2005 to 2006 school year In the
event that my child participates in activities of ULTRA Teen Choice, ULTRA Teen
Choice may assume that my child participates with my knowledge, consent and
permission. We/I expressly relieve
ULTRA Teen Choice from informing me of my child’s participation in ULTRA Teen
Choice activities. WE/I assume
responsibility of knowing when and if my child is participating in ULTRA Teen
Choice activities. In the
event that We/I wish to withdraw or nullify this release, We/I shall do so in
writing to ULTRA Teen Choice, P.O. Box 48608, Washington, DC 20002. Telephone:
202-544-5081. Contact Person: Richard
Urban, Executive Director. We/I have
read this release and execute it voluntarily. Date:____________________ Parent or
Guardian Signature ____________________________ Relationship
to child ____________________________ Address________________________________________
_______________________________________ Telephone Number ________________________________________ |