Minor's Name *
Minor's Name
Fill out one form for each minor.
Minor's Birthday *
Minor's Birthday
STATEMENT OF UNDERSTANDING: *
PFLAG is the nation's largest LGBTQ+ family and ally organization. Uniting people who are lesbian, gay, bisexual, transgender, and queer (LGBTQ+) with families, friends, and allies, PFLAG is committed to advancing equality through its mission of support, education, and advocacy. PFLAG Temecula is a local chapter of this national organization, and provides support to parents, family, friends, allies and members of the LGBTQ+ community in the Temecula Valley. PFLAG Temecula offers concurrent, biweekly adult and youth support groups for the Temecula Valley community. This waiver of liability authorizes your minor’s participation in the PFLAG Temecula Youth Support Group, as well as any social or outreach events hosted by PFLAG Temecula. I understand that participation in PFLAG Temecula Youth Support Group is voluntary and free of charge for all youth.
YOUTH SUPPORT GROUP FACILITATORS: *
The PFLAG Temecula Youth Support Group is facilitated by two adult board members of PFLAG Temecula, the Youth Director and Youth Liaison. Background checks are conducted and securely filed with chapter records on all PFLAG Temecula adult board members, including those working directly with youth. PFLAG Temecula board members strictly abide by a Code of Conduct as advised by PFLAG national and state and local laws governing the supervision of minors. Any member of the community may request a copy of PFLAG Temecula’s Code of Conduct policy in writing by emailing president@pflagtemecula.org. I also understand that the PFLAG Temecula Youth Support Group has a youth-nominated and youth-led “Youth Board” that is voted on once per year in October. The PFLAG Temecula Youth Board is responsible for co-facilitating the PFLAG Temecula Youth Support Group meetings with the Youth Director and Youth Liaison, as well as participating in committees for PFLAG Temecula to advance its mission and vision, including but not limited to, community outreach, social events, educational panels, social media outreach, etc. I understand that participation in the PFLAG Temecula Youth Board is voluntary and not a paid position.
WAIVER OF LIABILITY: *
This Waiver of Liability releases PFLAG Temecula from all responsibility, liability, and financial obligation relating to the participation of the above-named minor during, before, and following the above listed Youth Support Group, or any related PFLAG Temecula sanctioned or unsanctioned events, transportation, or activities. I understand that while every attempt will be made to ensure the safety and security of all participants and attendees at PFLAG Temecula events and meetings, PFLAG Temecula is not responsible for any injury, accidents or illness which may occur before, during and following any such events. Additionally, no youth shall be transported to events without their parent’s or legal guardian’s consent.
LIABILITY, LOSS, OR DAMAGE:
This Waiver of Liability releases PFLAG Temecula from any and all actions, claims, demands, or damages associated with participation in, or resulting from, any known or unknown injury, loss, or damage, sustained as a result of participation in the PFLAG Temecula Youth Support Group, or any sanctioned or unsanctioned activities related to or hosted by PFLAG Temecula.
YOUTH SUPPORT GROUP CONTENT: *
The PFLAG Temecula Youth Support Group mission is to provide a safe space for LGBTQ+ youth, and the youth family members and friends of LGBTQ+ members of the Temecula Valley, to receive support, fellowship, education and advocacy. The PFLAG Temecula Youth Support Group is a confidential support group environment where youth are given the opportunity to share their experiences with each other and to request support, education and fellowship with other youth participants. I understand that the PFLAG Temecula Youth Support Group is designed for youth ages 12-18, and PFLAG Temecula reserves the right to limit youth participation under 12 years old. I understand that mature content, graphic educational images and adult language may be discussed or viewed in the PFLAG Temecula Youth Support Group Meetings.
CONFIDENTIALITY AND MANDATORY REPORTING: *
All adult board members facilitating the PFLAG Temecula Youth Support Group are background checked and adhere to strict Code of Conduct and proper Support Group Facilitation guidelines, however, they are not licensed therapists. All adult board members facilitating the PFLAG Temecula Youth Support Group are held to strict confidentiality guidelines and cannot share any details about what is discussed in the support group meeting, except when information shared is serious enough to warrant disclosure to the legal guardians and/or proper authorities under the “mandatory reporting” guidelines by the State of California. I understand that I, nor any other adult other than the background-checked and trained PFLAG Temecula board members, may sit in on the PFLAG Temecula Youth Support Group meetings due to strict confidentiality guidelines.
OBLIGATIONS OF APPROPRIATE BEHAVIOR: *
I understand that PFLAG Temecula maintains, at its sole discretion, the right to dismiss anyone at any time for causing a disturbance. I recognize that PFLAG Temecula will not act in a chaperone’s capacity, nor will PFLAG Temecula provide any personnel to act in a chaperone’s capacity during Youth Support Group meetings or any other events or activities. All youth participants left unsupervised at any PFLAG Temecula support group meeting or event must be at least 12 years of age, with a maturity level that does not require adult supervision in order to effectively participate in activities or discussion.
I grant permission to PFLAG Temecula and its agents the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release PFLAG Temecula and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during interviews or guest lectures, with my name, for the purpose of outreach and publicity without restriction. This photo/video release form applies to all photographs and/or video images from this date forward, in perpetuity. I waive my right to any compensation now or in the future. I further acknowledge that I am able to REVOKE this photo/video release at any time, by sending an email request to PFLAG Temecula at media@pflagtemecula.org.
MEDICAL EMERGENCIES: *
I understand there may be risks associated with participation in, and transport to, event activities, and permit emergency medical treatment in the event of injury or illness to my youth. I authorize representatives from PFLAG Temecula to seek medical treatment for my youth in the event of an emergency, and assume all responsibility for expenses incurred, or which may occur, as a result of medical emergencies relating to participation in PFLAG Temecula events.
ACKNOWLEDGEMENT *
I further acknowledge that I am able to REVOKE this waiver of liability at any time, by sending an email request to the PFLAG Temecula Youth Director at youth@pflagtemecula.org. I acknowledge that I am:
Legal Guardian's Name *
Legal Guardian's Name
Legal Guardian's Phone # *
Legal Guardian's Phone #
Legal Guardian's Address *
Legal Guardian's Address
Emergency Contact's Name *
Emergency Contact's Name
Emergency Contact's Phone # *
Emergency Contact's Phone #