Healthy Plate Club Activities – Parental Release Form

You must have JavaScript enabled to use this form. Thank you for your interest in Inova's Healthy Plate Club activities.  Parents: Please read the following information and fill out the form below. Participant First Name Participant Last Name Participant Grade (current or upcoming) Parent / Legal Guardian First Name (If participant is under age 18) Parent Last Name Address Address Apartment or Unit Number City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Type - Type -HomeOfficeCell Phone Can we text you class updates and reminders? Yes No Select Your Cell Phone Carrier Select Your Cell Phone Carrier SelectNoneAT&TBoost MobileCricket WirelessGoogle Project FiRepublic WirelessSprintStraight TalkT-MobileTingTracfoneU.S. CellularVerizonVirgin MobileOther… Enter other… Email address Please list any allergies your child has to food or latex Photos for Marketing Purposes (See number 7 below) Yes, it is OK if my child's image is used for marketing purposes. No, do not use my child's image. Student's School Release, Waiver of Liability, and Media Authorization Form For Participation in Nutritional/Physical Activity Program I, the undersigned, desire to give permission for myself or the above-named child (of whom I certify that I am a parent or legal guardian) (“Child”) to participate in a nutritional/physical activity program sponsored by Inova Health System Foundation and/or a subsidiary thereof (collectively “Inova”) at the location identified above. I understand and agree as follows: I know of no reason, medical or otherwise, that would prevent Child/me from participating in this activity. I assume all risks of Child’s/my participation in this activity and full responsibility for Child’s/my conduct and actions, including any injury to myself, Child or others or damage to property that may result from Child’s/my participation, and I understand the Inova is not responsible for conditions created by other participants or by the location. I authorize the program and its volunteers to administer pre- and post-surveys to get feedback from myself or my Child. I also authorize the program to release age/grade, gender, race/ethnicity and other basic information to Virginia Cooperative Extension. I understand that such information will be used to demonstrate success of the program, and that individually identifiable information will not be shared publicly (as only de-identified, aggregated data will be shared publicly). I hereby release and hold harmless Inova, its trustees, officers, employees, and affiliates from any and all damages, claims, actions, liability and expenses (including costs of judgments, settlements, court costs, and attorney’s fees), regardless of the outcome of such claims or actions, arising out of or relating in any way to Child’s/my participation. I understand that Inova does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury, illness, death or property damage. I expressly agree that this release is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Virginia, and that this release shall be governed by and interpreted in accordance with the laws of the Commonwealth of Virginia. I agree that in the event that any clause or provision of this release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this release which shall nonetheless remain in full force and effect. I hereby authorize Inova, its facilities, and their employees and authorized agents and representatives to take photographs, videos or other recordings related to Child’s/my participation, and I consent to the use of such photographs, videos or recordings by Inova in any publication, website, program, presentation or other media, now or in the future, without compensation for me, for the purpose of education, telemedicine, marketing, development, community affairs, public relations, news media or healthcare communications, or other stories that will be read, seen and/or heard by the public. I understand that Child/I has/have the right to cease participating in any recording, filming or photography session. I have read and understand this form and have signed this voluntarily. Electronic Signature (participant) Electronic Signature (parent or guardian)