Emergency Medical Consent

I, the undersigned parent or legal guardian of relevant Scholar/s, consent to any of the staff, employees, agents and representatives of WRTL administering or consenting to the administration of such emergency medical care to the Scholar/s as such person deems appropriate in the circumstances, and hereby authorizes medical treatment in case of emergency.

I further authorize release of medical records and/or information pertaining to the diagnoses or treatment of the above-named Scholar/s when such disclosure is necessary for the purpose of evaluation, treatment or emergency care.

This form will remain in effect through the full calendar year of programming.

Parent/Guardian Roles, Responsibilities & Commitments

I, (Parent/Guardian), understand that the Wise Readers to Leaders program uses models, curriculum, and training which seeks to ensure every child a successful passage to adulthood with the help of caring families and communities. I understand that a key goal of the Wise Readers to Leaders program is to involve parents in the life of the program as active participants in the learning experiences of their children.

I understand that all adults, including parents, guardians, and adult family members of children enrolled in the Wise Readers to Leaders program, are expected to be positive role models, to communicate the importance of academic achievement, and to contribute to the creation of a caring and nurturing learning environment in which every child is valued and seen as capable of achieving.

I agree that during the time my child/children is/are enrolled in the Wise Readers to Leaders program, I will:

• Volunteer in the program.
• Participate in monthly parent meetings.
• Do my part to help make the Wise Readers to Leaders program a caring and nurturing learning environment.
• Ensure that my child/children is/are in attendance on a daily basis.

Wise Readers to Leaders – Participation & Liability Agreement

In consideration of the Scholar/s named in this application (the “Scholar/s”) being permitted to participate in Wise Readers to Leaders (“WRTL” or the “Program”), the undersigned, parent(s), or legal guardian(s) of the Scholar/s, on behalf of our heirs, executors, administrators and assigns, and the Scholar/s, hereby agree to the following terms and conditions set forth below:

Participation

I/We give permission for the Scholar/s to participate in the Wise Readers to Leaders program through the full calendar of programming in whatever format said program shall be whether virtual, in-person or hybrid. If the program is fully or partially virtual, I/we give permission for the scholar to use Zoom or any other media platform approved by Program staff.

Expectations

I/We understand and acknowledge that the Scholar/s is/are expected to abide by all WRTL/Stephen Wise Temple/Milken Community Schools/Brockton Avenue Elementary and any future site partner's (collectively referred to herein as “SITE PARTNERS”) regulations during the course of the Program. I/We agree that WRTL has the right to terminate the Scholar’s participation in the Program for any behavior deemed detrimental to the Program or the Scholar.

Hold Harmless

I/We acknowledge that as a condition of the Scholar/s participating in the WRTL Program, I/We hold harmless and waive any and all claims against Wise Readers to Leaders (“WRTL”), Stephen Wise Temple (“SWT”), and all future site partners, and its officers, employees, agents, and volunteers, including, but not limited to, claims arising out of any ordinary negligence of any officer, employee agent, or volunteer of the WRTL and SITE PARTNERS for any injury, accident, illness, or death, or any loss of damage to personal property occurring during or by reason of the Scholar participating in the Program, unless claim is based on gross negligence.

Voluntary Release of All Claims

I/We voluntarily release, discharge, waive and relinquish all claims that each may have against WRTL and SITE PARTNERS and, its staff, agents, employees, representatives, successors, and assigns (collectively the “Releases”), arising out of or in any way related to the Scholar’s/Scholars' participation in the Program, including, but not limited to, claims for bodily injury, personal injury, emotional distress, property damage or wrongful death occurring to the Scholar/s arising out of his/her/their involvement in the Program. This release, discharge, waiver and relinquishment also pertains to any instruction or supervision related to the Program on the part of WRTL, its officers, directors, trustees, employees and agents, unless claim is based on gross negligence.

Medical Care

I/We consent to any of the staff, employees, agents and representatives of SWT and WRTL administering or consenting to the administration of such emergency medical care to the Scholar/s as such person deems appropriate in the circumstances, and hereby authorizes medical treatment in case of emergency.

Medical Insurance

I/We understand and acknowledge that WRTL does not carry or maintain health, medical, or disability insurance coverage for the Scholar/s and therefore agrees to assume the responsibility for such insurance coverage on the Scholar/s.

Severability

If any provision of this agreement is held invalid or unenforceable, the remainder of this agreement shall nevertheless remain in full force and effect. If any provision is held invalid or unenforceable with respect to particular circumstances, it shall nevertheless remain in full force and effect in all other circumstances.

Voluntary Agreement

The Scholar/s and the parent(s)/guardian(s) acknowledge that they have read this Release and are aware of the legal consequences of signing this binding document. My signature below indicates that I have read and freely signed this agreement. I further certify that I am legally competent to sign this agreement.

Contact Information

Wise Readers to Leaders has my consent to release contact information, including phone number and email addresses to Wise Readers to Leaders Staff and Teen Volunteers.

Important – Read Entire Agreement Before Signing

Field Trip Permission & Waiver

Wise Readers to Leaders has special field trips planned which require your permission for your child to participate.

Authorization for Medical Care

Should it be necessary for my child to have medical care while participating in this trip, I hereby give Wise Readers to Leaders (WRTL) staff permission to use their judgment in obtaining medical care for the child, and I give permission to the nurse selected by WRTL to render medical care deemed necessary and appropriate. I understand that WRTL has no insurance covering such medical or hospital costs incurred by my child and, therefore, any cost incurred for such treatment shall be my sole responsibility.

Hold Harmless

I/We acknowledge that, as a condition of the Student’s participation in this activity, I/we hold harmless and waive any and all claims against Wise Readers to Leaders, its officers, employees, agents, and volunteers, including, but not limited to, claims arising out of any ordinary negligence of any officer, employee, agent, student or volunteer of the organization, or any loss or damage to personal property occurring during or by reason of the Student participating in this activity.