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DE ANZA COLLEGE ACADEMY SUMMER PROGRAM
PERMISSION / RELEASE & WAIVER OF LIABILITY / MEDICAL RELEASE FORM / MEDIA AND TECHNOLOGY
FORM
A parent or legal guardian must complete the following authorization form if the student is a minor child under 18 years of age. This form must be on file in the De Anza College Community Education office in order for the student to attend the on-campus / not-enrolled-for-credit De Anza College Academy Summer Program (“Program”). Due to the nature of some activities offered through this Program, participants and enrollees are hereby advised of inherent risks of possible injury. I, the undersigned, certify that I am the Parent/Legal Guardian of (Student Name), I hereby authorize enrollment of the named student in the De Anza College Academy Program at the Foothill-De Anza Community College District in order to permit the student to participate.
Release/Indemnification:
The Parent/Legal Guardian hereby consents to the above listed participation and release absolutely, forever discharge, hold harmless and covenant not to sue the Foothill-De Anza Community College District, its directors, employees, agents, volunteers and affiliates (herein collectively referred to as “District”) from any and all present or future liability, claims, demands, actions or rights of action, whether asserted by me or a third party arising out of, or in connection with minor student’s participation in the above activity, including claims of the District’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss suffered because of minor’s participation in this Program (the “Claims”). I agree to indemnify and hold harmless the District for any such Claims brought by me or a third party from any costs associated with defending or litigating such claims, including but not limited to attorney fees, costs and legal expenses.
Acknowledgement and Acceptance of Risks:
I hereby acknowledge that I have voluntarily chosen for my minor child to take part in any exercise activity or class offered through the Program. Certain risks are inherent in any such activity and cannot be fully eliminated, precluded, or controlled. I appreciate that these risks, some of which can contribute to the unique character and enjoyment of the activity, can also be the cause of injury. I hereby explicitly acknowledge, accept and willingly assume all risks and hazards related to, arising out of, or associated with my minor child’s participation in the exercise program; enrollment in the exercise program class confirms my consent.
Risk Release:
The De Anza College Community Education program always reserves the ultimate right, at any time, to accept, deny or terminate participation to and by any person. I hereby agree that my minor child will follow all rules, regulations, and the instructions of the De Anza College Community Education program and its employees while participating in this program. I also certify that my minor child is physically, mentally and emotionally capable of participating in these activities. I hereby represent that I have informed the De Anza College Community Education program of any pertinent medical conditions that may affect my minor child's participation in this program.
Medical Care / Emergency:
1. I give permission to the De Anza Health Services staff to deliver basic first-aid evaluation and treatment to my child in the event of minor injury or illness.
2. In the event of any medical emergencies, I authorize emergency transportation, emergency medical care and/or treatments including consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that the District deems necessary for the safety and protection of the minor student, and agree to be financially responsible for any medical services rendered.
I also want the District to know about all current medical problems including psychological difficulties and serious allergies (animal, food, medicine, etc.) and physical limitations as listed below, understanding that the District will not administer medicine during the program.
PLEASE NOTE THAT WHILE THE CONTRACTED FOOD PROVIDERS DO THEIR BEST TO FACILITATE ANY SPECIAL DIETARY NEEDS OR FOOD ALLERGIES, IT IS ASSUMED THAT MINOR PARTICIPANT WILL BE AWARE OF DIETARY NEEDS AND ALLERGIES AND WILL ACT IN ACCORDANCE TO HIS/HER PHYSICAL CONDITION.
COVID-19:
I am fully and personally responsible for my child’s safety and actions while participating in this Program. I have been informed and understand there remains a risk of exposure to COVID-19. I acknowledge that all students and participants in this Program are required to follow protocols and policies/procedures of the District and Santa Clara County Health Department regarding COVID-19. I understand that regardless of any precautions taken, an inherent risk of exposure to COVID-19 may still exist.
Emergency Medical Information:
In the event of an emergency, the parent(s) listed will be notified first. Please list additional emergency contacts below in case the parent(s) are unable to be notified. All emergency contacts below are authorized to pickup Minor Participant for non-emergency purposes. It is important that proof of personal medical insurance and emergency contact information for parents/guardians is provided and carried by the minor at all times. The college and emergency personnel will need this critical information.
Academy Rules and Code of Conduct:
Students must remain in the classroom and not wander away from instructors without permission. Students must not be disruptive in the classroom. Disruptive classroom behavior may include but is not limited to the following: talking when it does not relate to the discussion topic, sleeping, reading other material, being aggressive with other students, eating or drinking in the classroom without permission, refusing to participate in classroom activities, leaving cell phone on, texting, and engaging in any other activity not related to the classroom activity (without permission). Students who engage in disruptive behavior will be approached by the instructor and be given a verbal warning. If the disruptive behavior continues, District Officials reserve the right to dismiss any student who does not obey the Academy Rules and Code of Conduct and/or misbehaves and the parent shall be responsible to pick up minor child from the campus early.
Canvas (Instructure, Inc) & Zoom:
In order for Foothill- De Anza Community College District (“FHDA” or “District”) to provide your student with the most effective tools to enhance their learning, FHDA teachers may use various web-based educational program applications. Many of the Terms of Service and/or Privacy Policies of these applications state on their websites that, due to federal law, any users under the age of 13 must obtain parental permission to use their sites and often require information such as student’s name, email address or other personal identifier information be provided to the website operator.
Under federal law called the Children’s Online Privacy Protection Act (COPPA) these commercial educational websites must provide parental notification and obtain parental consent before collecting personal information. The law permits school districts to consent on behalf of parents to the collection of student personal information. This will mean that you will not need to provide consent on each and every web-based program that requires parental permission – the District will do that for you.
The De Anza College Community Education program delivers classroom instruction to students in an online educational learning environment using the Canvas course management platform operated by Instructure, Inc. Instructure’s privacy policy is available at https://www.instructure.com/policies/privacy. In addition, our webbased learning will be integrated with ZOOM, an online video and audio web conferencing platform, of which sessions may be recorded for instructional use. Your permission is required for the collection, use, or disclosure of your child’s personal information in connection with the De Anza Community Education programs offered through the Canvas course management platform and its online learning environment. FHDA website accounts provide access to FHDA content, materials, and resources relating to FHDA’s programs and activities, including programs offered through the De Anza College Community Education program. Unfortunately, if you do not provide this consent, your student will not be able to participate in online programs. (Student Name)'s enrollment in this class certifies my consent to the collection, use, or disclosure of my child’s personal information.
Media Release:
I hereby grant to De Anza College the absolute and irrevocable right and permission, with respect to the photographs or video taken of my child or in which he or she may be included with others, to copyright the same in the De Anza College name or otherwise; to use, reuse, publish, and republish the same in whole or in part, individually or in conjunction with other photographs, and in conjunction with any printed matter, in any and all media now or hereafter known, including the college website or advertising, and for any purpose whatsoever; and to use my child's name in connection therewith if the college so chooses.
I hereby release and discharge De Anza College from any and all claims and demands arising out of or in connection with the use of the photographs or video, including without limitation any and all claims for libel or invasion of privacy. We are willing to release this into the public domain and understand that no monetary compensation will be given for the use of the materials.
This authorization and release shall also inure to the benefits of the heirs, legal representatives, licensees and assigns of De Anza College, as well as the person(s) for whom the photographs or video were taken. I hereby consent to and grant permission the above named student to participate in the Program as specified above. I have carefully read the above information and releases and fully understand its terms and I sign it voluntarily and with full knowledge of its significance.
Release/Indemnification:
The Parent/Legal Guardian hereby consents to the above listed participation and release absolutely, forever discharge, hold harmless and covenant not to sue the Foothill-De Anza Community College District, its directors, employees, agents, volunteers and affiliates (herein collectively referred to as “District”) from any and all present or future liability, claims, demands, actions or rights of action, whether asserted by me or a third party arising out of, or in connection with minor student’s participation in the above activity, including claims of the District’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss suffered because of minor’s participation in this Program (the “Claims”). I agree to indemnify and hold harmless the District for any such Claims brought by me or a third party from any costs associated with defending or litigating such claims, including but not limited to attorney fees, costs and legal expenses.
Acknowledgement and Acceptance of Risks:
I hereby acknowledge that I have voluntarily chosen for my minor child to take part in any exercise activity or class offered through the Program. Certain risks are inherent in any such activity and cannot be fully eliminated, precluded, or controlled. I appreciate that these risks, some of which can contribute to the unique character and enjoyment of the activity, can also be the cause of injury. I hereby explicitly acknowledge, accept and willingly assume all risks and hazards related to, arising out of, or associated with my minor child’s participation in the exercise program; enrollment in the exercise program class confirms my consent.
Risk Release:
The De Anza College Community Education program always reserves the ultimate right, at any time, to accept, deny or terminate participation to and by any person. I hereby agree that my minor child will follow all rules, regulations, and the instructions of the De Anza College Community Education program and its employees while participating in this program. I also certify that my minor child is physically, mentally and emotionally capable of participating in these activities. I hereby represent that I have informed the De Anza College Community Education program of any pertinent medical conditions that may affect my minor child's participation in this program.
Medical Care / Emergency:
1. I give permission to the De Anza Health Services staff to deliver basic first-aid evaluation and treatment to my child in the event of minor injury or illness.
2. In the event of any medical emergencies, I authorize emergency transportation, emergency medical care and/or treatments including consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that the District deems necessary for the safety and protection of the minor student, and agree to be financially responsible for any medical services rendered.
I also want the District to know about all current medical problems including psychological difficulties and serious allergies (animal, food, medicine, etc.) and physical limitations as listed below, understanding that the District will not administer medicine during the program.
PLEASE NOTE THAT WHILE THE CONTRACTED FOOD PROVIDERS DO THEIR BEST TO FACILITATE ANY SPECIAL DIETARY NEEDS OR FOOD ALLERGIES, IT IS ASSUMED THAT MINOR PARTICIPANT WILL BE AWARE OF DIETARY NEEDS AND ALLERGIES AND WILL ACT IN ACCORDANCE TO HIS/HER PHYSICAL CONDITION.
COVID-19:
I am fully and personally responsible for my child’s safety and actions while participating in this Program. I have been informed and understand there remains a risk of exposure to COVID-19. I acknowledge that all students and participants in this Program are required to follow protocols and policies/procedures of the District and Santa Clara County Health Department regarding COVID-19. I understand that regardless of any precautions taken, an inherent risk of exposure to COVID-19 may still exist.
Emergency Medical Information:
In the event of an emergency, the parent(s) listed will be notified first. Please list additional emergency contacts below in case the parent(s) are unable to be notified. All emergency contacts below are authorized to pickup Minor Participant for non-emergency purposes. It is important that proof of personal medical insurance and emergency contact information for parents/guardians is provided and carried by the minor at all times. The college and emergency personnel will need this critical information.
Academy Rules and Code of Conduct:
Students must remain in the classroom and not wander away from instructors without permission. Students must not be disruptive in the classroom. Disruptive classroom behavior may include but is not limited to the following: talking when it does not relate to the discussion topic, sleeping, reading other material, being aggressive with other students, eating or drinking in the classroom without permission, refusing to participate in classroom activities, leaving cell phone on, texting, and engaging in any other activity not related to the classroom activity (without permission). Students who engage in disruptive behavior will be approached by the instructor and be given a verbal warning. If the disruptive behavior continues, District Officials reserve the right to dismiss any student who does not obey the Academy Rules and Code of Conduct and/or misbehaves and the parent shall be responsible to pick up minor child from the campus early.
Canvas (Instructure, Inc) & Zoom:
In order for Foothill- De Anza Community College District (“FHDA” or “District”) to provide your student with the most effective tools to enhance their learning, FHDA teachers may use various web-based educational program applications. Many of the Terms of Service and/or Privacy Policies of these applications state on their websites that, due to federal law, any users under the age of 13 must obtain parental permission to use their sites and often require information such as student’s name, email address or other personal identifier information be provided to the website operator.
Under federal law called the Children’s Online Privacy Protection Act (COPPA) these commercial educational websites must provide parental notification and obtain parental consent before collecting personal information. The law permits school districts to consent on behalf of parents to the collection of student personal information. This will mean that you will not need to provide consent on each and every web-based program that requires parental permission – the District will do that for you.
The De Anza College Community Education program delivers classroom instruction to students in an online educational learning environment using the Canvas course management platform operated by Instructure, Inc. Instructure’s privacy policy is available at https://www.instructure.com/policies/privacy. In addition, our webbased learning will be integrated with ZOOM, an online video and audio web conferencing platform, of which sessions may be recorded for instructional use. Your permission is required for the collection, use, or disclosure of your child’s personal information in connection with the De Anza Community Education programs offered through the Canvas course management platform and its online learning environment. FHDA website accounts provide access to FHDA content, materials, and resources relating to FHDA’s programs and activities, including programs offered through the De Anza College Community Education program. Unfortunately, if you do not provide this consent, your student will not be able to participate in online programs. (Student Name)'s enrollment in this class certifies my consent to the collection, use, or disclosure of my child’s personal information.
Media Release:
I hereby grant to De Anza College the absolute and irrevocable right and permission, with respect to the photographs or video taken of my child or in which he or she may be included with others, to copyright the same in the De Anza College name or otherwise; to use, reuse, publish, and republish the same in whole or in part, individually or in conjunction with other photographs, and in conjunction with any printed matter, in any and all media now or hereafter known, including the college website or advertising, and for any purpose whatsoever; and to use my child's name in connection therewith if the college so chooses.
I hereby release and discharge De Anza College from any and all claims and demands arising out of or in connection with the use of the photographs or video, including without limitation any and all claims for libel or invasion of privacy. We are willing to release this into the public domain and understand that no monetary compensation will be given for the use of the materials.
This authorization and release shall also inure to the benefits of the heirs, legal representatives, licensees and assigns of De Anza College, as well as the person(s) for whom the photographs or video were taken. I hereby consent to and grant permission the above named student to participate in the Program as specified above. I have carefully read the above information and releases and fully understand its terms and I sign it voluntarily and with full knowledge of its significance.
