GIRLS LEAD OTHERS WISELY (GLOW) OFFERS DYNAMIC 8-WEEK PROGRAMS FOR GIRLS AGED 9-14. EACH SESSION FEATURES A GLOW CIRCLE, CREATING A SPACE FOR MEANINGFUL, AGE-APPROPRIATE CONVERSATIONS. ALONG WITH INSPIRING DISCUSSIONS, PARTICIPANTS WILL ENJOY FUN, CREATIVE PHYSICAL ACTIVITIES THAT PROMOTE TEAMWORK, CONFIDENCE, AND LEADERSHIP.

Confidentiality Agreement

I understand that the information I give to GLOW is private and confidential.

I agree that any information I acquire regarding other girls of GLOW is to remain confidential and I will not discuss GLOW girls outside of GLOW programs and services.

The GLOW Coordinator and Volunteers are bound by strict confidentiality requirements. All meetings are confidential within the program, unless otherwise specified.

Legal exceptions to the confidentiality agreement exist:

In cases of imminent danger to the girl or others, or actual or suspected child abuse, GLOW's Coordinator is legally obliged to notify the proper authority.

In the case of a subpoena to a court of law, GLOW will be required to answer questions and submit files.

Please note:

Confidentiality will be waived in situations where there is a risk to an individual's physical and/or emotional health and safety, including that of a minor child (under 18 years of age). The law requires all adults having knowledge of such circumstances to report this information to the Police or Child and Family Services in your area. In case of such an event, every effort will be made to ensure that you and your family are supported in this process.

Waiver and Release from Liability

1. Subject. Participant recognizes and expressly agrees that participating in the GLOW program associated with indoor and/or outdoor activity is an inherently dangerous activity. Further, Participant recognizes that certain safety precautions must be followed, yet even strict adherence to those procedures does not guarantee nor does GLOW Program Inc. guarantee Participant's safety.

2. Waiver and Release from Liability. Participant understands that GLOW Program Inc. assumes no responsibility for injuries or illnesses that Participant may sustain, a) as a result of Participant's physical condition, b) resulting from Participant's participation in the activity, c) as a result of another participant's or third person's actions, or d) as a result of participant's use of GLOW program Inc. facilities, field, and/or equipment in connection with this activity.

The Participant releases and agrees to hold harmless, defend and indemnify GLOW Program Inc. and its directors, officers, employees and agents from and against any and all claims for personal injury (including loss of life) and all other losses or damages (except those caused entirely by the gross negligence or intentional conduct of GLOW Program Inc.) that the Participant may suffer as a result of his or her participation and /or enrolment in GLOW Program Inc. activities.

3. Medical Consent. Participant grants permission to Glow Program Inc. and its employees and agents to take the Participant to a licensed physician for medical treatment, emergency surgery, or hospitalization if Participant becomes ill, sustains an injury, or otherwise requires medical treatment or attention and GLOW Program Inc. is unable to contact the Emergency Contact listed by Participant. The Participant gives consent to any licensed physician to administer drugs or medicine or to perform such medical procedures as that physician determines necessary for the relief of pain and to preserve the Participant's life or health. Participant further authorizes GLOW Program Inc. to give first aid, CPR or other treatment by a qualified staff member to Participant.

4. Behaviour. The teaching and modelling of key values such as integrity, compassion and respect will set the stage for open communication. In the event of a repeated display of inappropriate behaviour, a verbal warning will be given by GLOW program Inc. Should the behaviour continue, GLOW Program Inc. will call the girl's parents to discuss the situation. If, after warning and discussion, there is no improvement in the girl's behaviour, she will be asked to leave the program.

5. Property Loss. Participant understands and agrees that GLOW Program Inc. is not responsible for personal property that is lost, damaged, or stolen in connection with this activity.

6. Binding Effect. This Agreement shall be binding upon Participant, his or her heirs, estate,

successors, and legal representatives.

7. Entire Agreement. This Agreement represents the entire agreement between the parties. This Agreement shall not be modified or amended except by an agreement in writing signed by both parties.

Acceptance. If any portions of this waiver and release are held to be invalid, Participant agrees the remaining terms shall continue to be in full legal force and effect. Participant understands and agrees that this Waiver and Release is binding upon me and my heirs, estates and legal representatives.

Media Release: I grant GLOW Program Inc. the absolute right to copyright, re-use, publish and republish by any medium, including electronically, any photos of my child or in which they may be included, that may be taken while participating in GLOW Program Inc. activities.

Participant's Name

First Name

Last Name

Date of Birth

YYYY

Age

Special Accommodations, Health and Medical Concerns

Name of Parent/Guardian

First Name

Last Name

Relationship

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Daytime Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

I consent to and accept the terms and conditions of the confidentiality agreement.

Yes

PLEASE READ CAREFULLY. THIS DOCUMENT CONTAINS A RELEASE AND WAIVER OF LIABILITY. I have read and voluntarily consent to the terms and conditions this Waiver and Release of Liability.

Yes

Media Release

Decline

Kinzua Youth Development Center