Ultimate Impact Waiver and Release Forms

Thank you very much for taking the time to fill this out and help us
improve our programs. We understand that your time is important
so this should take less than 10 minutes to complete. This form is TWO pages. Please complete the below form, hit submit and then submit your digital signature on the next page. 

You have the option to opt out but signing each form enables youth to fully
participate in Ultimate Impact’s programs. If you have any questions, please email us at programs@ultimate-impact.org. 
Youth Information
By filling out Youth Mobile Phone and/or Youth Email below, you give consent for Ultimate Impact staff to communicate program and event logistics with this youth phone number and/or email.
Parent/Guardian Information
Participation Waiver and Photo Release
By signing this Comprehensive Waiver and Release Form (“Release”), I agree to the terms below, which cover the following topics: (1) a waiver and release of liability, (2) an agreement to assume risk, (3) a permission to obtain medical treatment and (4) a photo and publicity release. 

I understand that the named minor(s) (“Minor(s)”) below will benefit from participation activities (“Ultimate Impact Activities”) organized by Ultimate Impact, Inc. (“Ultimate Impact”), which include such activities as spectating or participating in the sport of ultimate (“Ultimate”), playing in Ultimate games against players from other teams, playing in tournaments organized by Ultimate Impact or other entities, scrimmaging, participating in other activities arranged by Ultimate Impact related to Ultimate, and travel to and from such activities. In exchange for such benefit, I, as parent and/or legal guardian of the Minor(s), for myself, the Minor(s), my and the Minor(s)’ heirs, executors and administrators, agree as follows:

1. To release, waive, discharge and otherwise hold harmless Ultimate Impact and its officers, directors, employees, program partners, agents and volunteers, acting officially or otherwise, from any and all claims, demands, actions or causes of action that in any way arise from the Minor(s)’ participation, and/or my participation, in the Activities.

2. To the best of my knowledge and belief the Minor(s) is/are in good health. I understand and agree that participation in the Activities and/or use of the spaces where Ultimate is played can be hazardous and involve the risk of physical injury. Recognizing there are risks and potential dangers to participating in the Activities, I give my consent and voluntarily choose to allow the Minor(s) to participate in the Activities, and expressly assume all risks and dangers of such Activities, whether or not described in this Release, known or unknown, inherent or otherwise.

3. In the event that I, or other parent/legal guardian, cannot be reached in an emergency, I give permission to Ultimate Impact, its agents and representatives to secure proper treatment for the Minor(s). I consent to any medical, surgical or dental treatment and hospital or other care as is considered necessary by the attending physician, surgeon, dentist or other medical professional providing care to the Minor(s). I further understand and agree that I will assume full responsibility for any such treatment, including payment of costs.

4. I acknowledge that Ultimate Impact’s Activities and participants may be occasionally photographed, videotaped or audio taped. I give my permission to Ultimate Impact, its agents and representatives to use, without any compensation, the Minor(s)’ image, voice and likeness contained in any photos, video recordings, audiotapes, digital images or the like, and the Minor(s)’ name and biographical information, for any purpose related to Ultimate Impact’s Activities and mission, including as part of promotional brochures, slide shows, websites, or other media of any kind.
General Active Family Consent Form
Ultimate Impact collects participation surveys from our youth throughout the year. The feedback will help us work together to make sure we are offering great programs for youth. 

Overview of Key Points

1) The survey will take less than 15 minutes to complete and it is not a test nor are there right or wrong answers. It is a survey of your child’s experiences and opinions about participating in Ultimate Impact’s programs.  The youth will be reporting their thoughts and feelings about how our programs are doing as well as some information about themselves (e.g., age, gender, race-ethnicity). Your child’s responses will help us improve our programs for youth and families. 

2) Participation is optional/voluntary and there will be no consequences if your child does not want to participate. Your child will be told of their right to skip any question they do not want to answer and they can end their participation at any time.

3) While we ask that each youth use their name, it is not required. The reason we ask for youth names is so that we can see how effective our programs are at the beginning of a year, semester, or summer as compared to the end. Student names will not be included in any data reports.

4) There are no risks to participating in this survey. Individual surveys are not shared with anyone.

5) A copy of the survey is available for your review if requested.

The impact of a survey of this kind depends upon the participation of many youth. We hope you will encourage your child to participate. In doing so, they will help strengthen the experience for youth in Ultimate Impact.

If you will allow your child to participate, please complete and return the form. If we don’t receive this signed form, your child will not be allowed to participate. If you have any questions, please contact us at programs@ultimate-impact.org. Thank you!
Partnership with San Francisco's Department of Children, Youth and Their Families and Authorization for Release of Confidential Student Information
Can we share your information with the San Francisco Department of Children, Youth and Their Families?

The San Francisco Department of Children, Youth, and Their Families (DCYF) funds our agency and the services we provide. To fulfill the requirements of this funding, we share information about the participants in our services with DCYF. DCYF and the San Francisco Unified School District (SFUSD) maintain a shared, secure database to record information about services provided to San Francisco youth by DCYF’s grantees in order to facilitate outreach and enrollment and track program use and impact. As a DCYF grantee, our agency has access to the shared database to both see and report data about the youth we serve. The data that we report to DCYF is also shared with SFUSD.

By signing this form, you authorize1. Our agency to share information about your child’s participation in our program (or your participation, if you are 18 years of age or older) with authorized staff at DCYF and SFUSD for the purposes described above. The information that our agency reports to DCYF includes: Person information, such as name, date of birth, and address: Demographic information, such as race/ethnicity and gender identity; Education information, such as school name and grade level; Participation in activities and services, such as dates of attendance dates and hours attended; and, Anonymous and voluntary youth experience surveys.2. SFUSD to share certain information about your child (or you, if you are 18 years of age or older) with authorized staff from our program as a DCYF grantee. The information that SFUSD reports to DCYF includes: Personal information, such as name, date of birth, and address; Education information, such as school name and grade level; and; Dates of attendance in SFUSD or an SFUSD school.

DCYF, SFUSD, or our agency will not publicly report any information that we provide in a way that may be used to identify your child (or you, if you are 18 years of age or older).Restrictions: All information that we provide or access that is related to an SFUSD student is protected by federal and state laws that govern the use, disclosure and re-disclosure of student education records. Parties other than DCYF, SFUSD and our agency will not have access to any personally identifiable information that is reported into the database, except to the extent that the parties have obtained prior written authorization from you or have followed SFUSD policies and procedures to obtain access to such information.

Expiration: This authorization expires on June 30, 2024.

Your Rights: You may refuse to sign this form. You may cancel it at any time by information our agency in writing. If you cancel your permission allowing us to release information to DCYF and SFUSD, and SFUSD to our agency, it will go into effect immediately, unless the information has already been released. You have a right to receive a copy of this form.

Contact Information