Thank You – Express Yourself

PHOTOGRAPHY/MEDIA CONSENT AND RELEASE

Empower Simcoe sometimes asks people to let us use their photo, video or audio to promote Empower Simcoe’s work or
tell others what we do.

I understand that a photo, video or social media posting may appear in public promotional material for many years.
Empower Simcoe may, at any time, reproduce, publish and/or republish the video, photograph(s) or audio for
any communication, advertising and/or promotional purposes, including the posting of the video or any portion thereof
on the agency’s websites.

This consent will remain valid for one year from the date signed.

Authorizing person(s) may cancel or change the above authorization in writing at any time prior to the expiry date, unless
action has already been taken on the basis of the authorization.

I hereby give my/our permission and consent to Empower Simcoe to collect and use Photography and/or Video of this participant to promote and advertise the programs & services of Empower Simcoe.

WAIVER AND CONDITIONS OF ENROLMENT

1. The parent/guardian(s) or authorized support staff of the above-named participant, release the Ex-press Yourself course, its Community Participation Support Workers, Supervisor, and Volunteers from any loss, personal injury, accident, misfortune or damage to the above-named or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named participant.
2. In case of medical emergency, the parent/guardian(s) of the above-named participant understands that every effort will be made to contact them. In the event that the parent/guardian cannot be reached, I/we give permission to the Empower Simcoe Staff and the attending doctor to secure medical treatment for and/or hospitalize the above-named participant.
3. Empower Simcoe reserves the right to dismiss or not accept a participant who, in our opinion presents a hazard to the safety and rights of others, or who appears to have rejected the reasonable controls of the program. Failure to disclose any medical, emotional or behavioural conditions on this form could results in the participant being excused from Ex-press Yourself without refund.
4. If it is determined that a participant requires a 1:1 support worker, the parent/guardian or authorized support staff is responsible for arranging this support, a participant may not be invited back to our program until a suitable support is in place.
5. REFUND POLICY: Cancellation more than two weeks prior to the start of the course – full refund less $50.00 administration fee. Withdrawal during the course on physician’s order – one half of fee for unexpired term will be refunded. No refund will be made for dismissals due to disciplinary action, late arrivals or early departures.

I have read and hereby agree with the waivers and conditions of enrolment.