NCCJ Programs - Parent Consent Form

Parent/Guardian First and Last Name

Student First Name

Student Last Name

Student Email

School Name

Dear parent/guardian,

The National Conference for Community and Justice of the Piedmont Triad (NCCJ) is a human relations organization that seeks to bring people together to create compassionate communities in the Triad.

This form seeks consent for your student to participate in NCCJ's in-school program, "Break the Cycle: Be the Change" at your student's school. This form also seeks consent for NCCJ to use photos taken during the program.

Break the Cycle is a 90-minute human relations program for high school students. The assembly-style session guides student participants through the 7 phases of the cycle of prejudice. Our goal is to help raise student awareness of issues that may affect them and their peers, to challenge their thinking on these matters and to perhaps change how students act as it relates to building relationships with others.

A representative from your child’s school will also be present for the duration of the program.

Please confirm your consent for your child’s participation by checking the appropriate box below. Make sure to check the date and time of the NCCJ program at your student's school.

Please check the box that applies:

I grant permission to my student to participate in NCCJ's programming.I do not grant permission to my student to participate in NCCJ's programming.

PHOTO RELEASE

I understand that l, alone or with other participants and/or NCCJ staff, volunteers or representatives, may be interviewed, photographed, recorded on film, audio tape, or other visual and sound computerized, telephonic, voice-mail or tape media ("photographs and/or sound/ image recordings") and/or may provide written or

oral statements to NCCJ and/or others approved by NCCJ.

I hereby consent to the foregoing and grant permission, without reservation, to NCCJ and/or those approved by NCCJ to generate, prepare, advertise, describe and/or publicize NCCJ and its work, good will, public education and/or fundraising activities, disseminate, otherwise use and comment upon the photographs and/or sound/image recordings

as they may determine, without review by me and without financial or other obligation of any nature to me.

I consent that I may be identified by name, age or otherwise, as NCCJ and/or those approved by NCCJ may determine.

I release NCCJ, its officers, Board members, volunteers, agents, employees and licensees from all claims that I may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/ image recordings as set forth herein.

This consent and release shall continue in effect, without a limitation of time.

I do consent and agree to the photo release terms mentioned above.I do not consent and agree to the photo release terms mentioned above.

Please type your full name in the box below to electronically sign.

Parent/Guardian Signature (if person above is under 18)

Parent/Guardian Email Address

If you have any questions about our program, feel free to get in touch with either your school contact, or our assistant program director, María Perdomo (mperdomo@nccjtriad.org).

If you'd like to learn more about NCCJ, check out our website www.nccjtriad.org