1700 N. Australian Ave., West Palm Beach, FL 33407 • 561-833-1461 • www.ulpbc.org
To be completed by Parent/Guardian on Behalf of the child
I hereby grant permission for my child’s school to release attendance, conduct records, and grades to the Urban League of Palm Beach County, Inc. I understand ULPBC uses the participants’ information to improve their participation in the program.
Youth Project Consent Form
Your child has been chosen to participate in the NULITES Program at Urban League of Palm Beach County, Inc. Program participants, with the guidance of Urban League of Palm Beach County, Inc. staff will explore their goals for the future and participate in activities to prepare them for college, work, and life. Your child will be involved in service learning projects in the community to further their preparedness. The program promotes progress in school and avoidance of behaviors which may hinder your child’s most successful growth and achievement.
Please initial the consent below
Consent to Participate in the NULITES Program, I, the undersigned, am the Parent or Guardian of the child named below who is to participate in programs provided by Urban League of Palm Beach County, Inc. during the current school year. I am aware that there are potential hazards and risks involved in some programs. I am willingly allowing the child mentioned above to participate in all aspects of the program (including field trips and transportation) under the supervision of Urban League of Palm Beach County, Inc. staff. Agency staff will accompany off site activities. I agree to hold harmless and indemnify Urban League of Palm Beach County, Inc., its Board of Trustees, and/or its employees, agents, or lessors from any and all claims by myself, my teen, my heirs, my family, or my assigns.
Consent to Use Photographs I give my consent to Urban League of Palm Beach County, Inc. to use videos and/or photographs of my teen for brochures, to display in photo albums, in advertisements, or for other publicity purposes. If my teen’s photo is used, he/she/they will only be identified by first name.
Parent or Guardian Signature OR Teen Signature if 18 or over or emancipated
Tomas Evangelista Sr. Director of Programs and Operations
Urban League of Palm Beach County, Inc. 1700 North Australian Avenue 561-833-1461 ext. 3025 Fax: 561-296-9727 Email: firstname.lastname@example.org
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To assist African-Americans and other minorities in the achievement of social and economic equality.
1700 N. Australian AvenueWest Palm Beach, FL 33407