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PARENTAL CONSENT & MEDIA RELEASE FORM
PARENTAL ACKNOWLEDGMENT, CONSENT AND RELEASE
I, ________________________________________________ the parent/guardian of
____________________________________, give my consent of her participation in Tech Savvy that will be held
at Boston University, Northeastern University Wentworth Institute of Technology, and UMass Boston. I have gone
over the agenda and I am aware that my daughter will be traveling by bus to some of these venues and participating
in hands on activities. I understand that the university has made no representation concerning the safety of the
methods of travel to and from or the travel sites visited. I recognize that it is my responsibility to ask questions
about any aspect of the program that has not been explained to my satisfaction.
In exchange for the benefits that my child will receive by participating in this program I hereby voluntarily
agree, on behalf of myself and my child, to assume all of the risks in connection with my child's attendance at and
participation in Tech Savvy, including travel, and I agree to release Boston University, Northeastern University
Wentworth Institute of Technology, and UMass Boston from any and all liabilities and claims whatsoever arising
out of ordinary negligence in connection with my child's attendance and participation in the aforementioned
program.
The term Boston University shall include the corporation named Trustees of Boston University and its
successors, trustees, officers, agents, representatives, contractors and all persons for whose conduct the University
is, or could be legally responsible.
The term Northeastern University shall include the corporation named Trustees of Northeastern and its
successors, trustees, officers, agents, representatives, contractors and all persons for whose conduct the University
is, or could be legally responsible
The term UMass Boston shall include the corporation named Trustees of UMass Boston and its successors,
trustees, officers, agents, representatives, contractors and all persons for whose conduct the College is, or could be
legally responsible.
The term Wentworth Institute of Technology shall include the corporation named Trustees of Wentworth
Institute of Technology and its successors, trustees, officers, agents, representatives, contractors and all persons for
whose conduct the University is, or could be legally responsible.
I agree that the laws of the Commonwealth of Massachusetts shall govern this Acknowledgment, Consent
and Release. I affirm that I have read and understood this document.
Date Signature of Parent or Guardian
MEDIA RELEASE
I hereby give my permission, Boston University, Northeastern, Harvard University, UMass Boston, and
Wentworth Institute of Technology to photograph, film, videotape and/or make sound recordings of my child, to
quote or publish statements of my child and to use such photographs, films, videotapes, sound recordings and/or
other statements for educational and promotional/advertising materials and for other purposes specified below. I
understand that my child may be identified in any photographs, news stories or publications that the aforementioned
institutions consider appropriate for release to magazines, newspapers, the World Wide Web sites of these
institutions, and/or other publications. I further understand that any such photographs, films, videotapes, sound
recordings and/or written works are the property of these institutions and that neither my child nor I am entitled to
any compensation for or rights in these materials.
I release these institutions from all liability with respect to the matters covered by this release.
Date Signature of Parent or Guardian