One Time Registration

Individual Registration

1Account Details

2Agreement

3Billing Details

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Account Details
Pariticpant First Name*
Pariticpant Last Name*
Participant Email*
Pariticipant Phone*
Additional Details
Parent/Guardian 1 First Name*
Parent/Guardian 1 Last Name*
Parent/Guardian 1 Email*
Parent/Guardian 1 Cell Phone*
Parent/Guardian 1 Alternate Phone
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Email
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Home Phone
Participant Faith Tradition*
ALLERGIES, MEDICAL, and/or OTHER ISSUES:

Please provide any information that will help us ensure a safe and positive experience while we are working with your child (food and other allergies, medical concerns, or other issues we should be aware of)
RELIGIOUS AND OTHER DIETARY NEEDS:

Please provide any information we may need in order to support religious or other dietary needs, including halal or kashrut needs, vegetarian, etc.
Participant's Gender (Optional)
Grade Entering 2021-2022*
House of Worship (if any)
Participant Town of Residence
Participant Date of Birth*
MM slash DD slash YYYY
Youth's FULL Home/Mailing Address*
Parent's FULL Home/Mailing Address (if different)
Youth lives with*

Youth Permission and Waiver
THIS FORM MUST BE COMPLETED BY ONE CUSTODIAL PARENT/GUARDIAN OF THE CHILD.
Youth Permission*

By signing above, I, the undersigned parent/legal guardian of the above youth participant (the “Youth”) grant express permission for the Youth to participate in a children’s program (the “Program”) operated by Mosaic: Interfaith Youth Action (the "Organization”). I understand that in this form the Organization includes the staff, board members, and volunteers. Program activities may include, but are not necessarily limited to: - In-person and online community and team-building activities, educational activities, guest speakers, discussions and dialogues, overnight programs, project-based learning, mentoring, service projects, and other action activities such as advocacy, letter writing, lobbying, etc. - Site visits such as to houses of worship to observe religious services and rituals, to host events with youth in other communities, or activities such as bowling, beach day, mini-golf, etc. - At home activities: the participant may be invited to undertake activities on their own time, such as, but not limited to, online research, meeting with community leaders, project planning, advocacy, letter writing, lobbying, service projects, etc. Please type your full name, which will act as your electronic signature
Transportation*

I further understand that it is my responsibility to arrange for adequate transportation for my Youth at the conclusion of in-person programs and to adequately communicate post-program transportation plans to both my Youth and to the Organization staff. In addition, I understand that if I give my Youth permission to take public transportation and/or ridesharing services (such as Lyft or Uber) at the conclusion of programs that I am responsible for all costs and risks. I agree that the Organization is not liable or responsible during any post-program transportation, including in cases in which the Organization helps to establish carpools between families. . Please type your full name, which will act as your electronic signature
Awareness and Assumption of Risk*

While the Organization takes every precaution (both for physical and socio-emotional safety) before, during, and after all programming, the Youth’s participation in the Program, including each of the activities offered as part of the Program involves a level of risk. By signing below, I understand that the Youth’s activities in the Program have inherent risks that may arise from the activities themselves, my Youth’s own actions or inactions, the actions or inactions of the Organization, its directors, officers, employees and agents, volunteers, and others present at the program, transportation to and from Program sites, and dangers and conditions at Program sites or during virtual programming. I assume full responsibility for any and all risks of bodily injury, death or property damage caused by or arising directly or indirectly from my Youth’s presence at Program sites or participation in the Program virtually or in-person, regardless of the cause. All risks cannot be listed on this form but may include, data mining, phishing, viruses, malware, data breach of online information, cyberbullying, exploitation, victimization, cyber stalking, online grooming, cyber predators...etc. for online programming. Many of these risks are inherent in any use of the Internet. Any additional risk of damage to equipment including but not limited to smartphone, computers, etc. is the sole responsibility of the owner of said equipment. In person risks may include physical injury, bullying, victimization, etc., as such risks are inherent in in-person programming. Please type your full name, which will act as your electronic signature
Release of Claims*

In consideration for my Youth’s participation in the Program, I waive and release any and all claims against the Organization, its directors, officers, agents, employees, volunteers, and affiliates (collectively, the “Organization Parties”), for any liability, loss, damages, claims, expenses and attorneys’ fees resulting from death or injury to the Youth or property, caused by or arising directly or indirectly from the Youth’s presence at Program sites or participation in the Program, regardless of the cause and even if caused by negligence, whether passive or active. I agree not to sue any of the Organization’s Parties on the basis of these waived and released claims. . Please type your full name, which will act as your electronic signature
Idemnification*

I will defend, indemnify, and hold the Organization Parties harmless from and against any and all liabilities, losses, damages, claims and attorney’s fees that may be suffered by any Organization Party resulting directly or indirectly from my Youth’s presence at Program sites or participation in the Program, except and only to the extent the liability is caused by the gross negligence or willful misconduct of the relevant Organization Party. Please type your full name, which will act as your electronic signature
Medical Care Consent*

I authorize the Organization to provide to my Youth first aid and administer medication or seek medical attention for the Youth if an emergency arises. In addition, I waive and release any claims against the Organization Parties arising out of any first aid, treatment or medical service, including the lack or timing of such, made in connection with my Youth’s activities in the Program. Please type your full name, which will act as your electronic signature
Emergency Contact Name*

In case of an emergency, staff would contact this individual
Emergency Contact Phone Number*

Please enter the phone number for thhttps://mosaicaction.org/wp-admin/admin.php?page=gf_edit_forms&id=1#add_fieldse Emergency Contact listed above.
Contact Sharing*
I the undersigned give permission for the Organization staff to share my contact information and my child's contact information (phone number and email address) with other Organization participants and parents/guardians for the purposes of helping Organization participants connect with one another and work collaboratively. Please type your full name, which will act as your electronic signature
Media Agreement*
I consent to the use by Organization of my Youth’s image, voice, name and/or story in any format, including video, print, or electronic (collectively, the “Materials”), as the Organization may deem appropriate to promote its programs. Organization may make the Materials available at its discretion to third parties, on Organization’s website, in Organization’s publications, or through any other media, including social networking websites. I waive any right to inspect or approve the finished product or to receive any payment. I grant to Organization all copyrights in the Materials and waive any legal claims, including those relating to copyright, or rights of publicity or privacy.. I understand that the full name of my Youth will not be identified in any such photos/recordings.
News Permission*
We occasionally have reporters from news media cover Mosaic programs. If an invited reporter would like to print a photo or quote from your child, please check below to give permission
Date*
MM slash DD slash YYYY

Billing Details
Registering For...*
If registering for the Religious Observance who will be in attendance? Please list everyone who will be attending
Billing Name
First Last
Billing Email*
Total
$0.00
Coupon
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Coupon
Total:
$0.00
Credit Card
Card Details
Cardholder Name
Untitled
Name
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One Time Registration

Individual Registration

Account Details

Additional Details

Youth Permission and Waiver

Billing Details