I hereby give consent and permission to any licensed physician to hospitalize and secure proper treatment for and to above named child whose health history appears on the reverse side if needed. This form may be photocopied for use during the program.

I hereby waive any and all claims and demands of whatever nature, which I have or may hereafter acquire against the Township of Stafford, its officers, the Youth Police Academy, its officers and agents, as a result of my permission for my child’s participation in the Youth Police Academy from July 11-15, 2022.  I further agree that my child will comply with all rules of the program and any instructions or orders issued by the program coordinators in connection with the program. I hereby acknowledge that I fully understand the consequences of this waiver and that it is a voluntary and intelligent act on my part and my child.

I grant permission for the Stafford Township Police Department and its subordinates, to use my son or daughter’s name and/or photographs for use in any media publications, or newsletters. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless the Stafford Police Department and subordinates, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I certify that I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.