BEYOND DIFFERENCES STUDENT PERMISSION SLIP
Beyond Differences Student Filed Trip/Excursion Permission Slip

For more information, visit www.beyonddifferences.org/students/teen-board/


Or call us at 415-256-9095 (Marin office)
  • Retreats

    Please list your family’s order of preference of dates. Please know that we cannot guarantee what day your child will be assigned, but will do our best to meet families’ preferences. Please select your first choice.
  • Parent or Guardian Signature:
  • Contact Information:

    Emergency Number(s) for Parent/Guardian:
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  • Alternate Emergency Contact

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  • Student Personal Information:

  • Student Health Condition Information:

  • Medication Information:

    All students with asthma, diabetes, and severe allergies should have emergency medication available that they carry or give to staff in the event of an asthma attack, low blood sugar, or allergic reaction along with a Severe Allergy/Asthma Action plan signed by you and your doctor. See your School Nurse/Health Services for more information.
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  • Health Insurance Plan

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  • FOR HIGH SCHOOL STUDENTS ONLY (Grades 9-12):

    With permission of the parent/guardian and the supervising staff, a high school student may meet at and/or leave from the destination on his/her own. Please check below if you grant permission to your high school student to arrive at or leave the destination on his/her own. Under this option, Beyond Differences is not liable for any incidents that may occur.
  • Important Notice & Waivers:

    California Law provides as follows: All persons making the field trip or excursion shall be deemed to have waived all claims against Beyond Differences or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion. (Education Code Section 35330).

    I understand that there are some risks involved in the trip covered by this permission form. I expressly and voluntarily assume all risks in connection with or arising out of my son/daughter/ward’s participation in the trip. I acknowledge there may be other risks not known to me or not reasonably foreseeable at this time and am hereby waiving any and all rights and benefits conferred by any statute, regulation, or principle of common law or civil law of the United States, of any state, commonwealth, territory, or other jurisdiction thereof, or of any foreign country or other foreign jurisdiction which is similar, comparable, or equivalent to Section 1542 of the California Civil Code which provides as follows:

    SECTION 1542. A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.

    I also hereby release, discharge and covenant not to sue or make any claim against, Beyond Differences or any of its directors, officers, employees or agents (“Releasees”) and hereby waive any and all claims against the Releasees for any actions, demands, losses, damages, liabilities, costs, or expenses in connection with, arising out of, or related to my son/daughter/ward’s participation in the trip.

    Consent and Release for Pictures, Video, and Recordings

    Beyond Differences holds events and activities in which students might be photographed, video-taped, filmed, or recorded. In order for these pictures, videos, and recordings to be used by Beyond Differences and authorized third parties, parents or guardians must consent to and release rights to them by agreeing to the following:

    I am the parent/guardian of the above-named student. I have been informed by Beyond Differences that my child will participate in planned activities throughout the year where my child might be photographed, videotaped, filmed or recorded by Beyond Difference staff or a third party. I understand this is a valuable learning experiences for my child, and I agree to allow my child to participate in this activity or event as stated in this Consent and Release Form.

    I authorize Beyond Differences, or any third party it has approved, to record my child’s name, likeness, image, voice and performance through film, photograph, pictures, videotape, digitally or through any other process as part of the activity or event. I further agree that any recording may be edited at the sole discretion of Beyond Differences, or any third party Beyond Differences approves, and used in whole or in part by Beyond Differences, or any third party Beyond Differences approves, for any and all broadcasting, publication, distribution, training, audio/visual, or exhibition purpose in any manner or media.

    I understand that I and my child shall have no intellectual property or other legal right or interest in or arising from the recording in any way, including but not limited to any royalty or other economic right or interest that could arise from any publication, broadcast, or reproduction of the recording or the activity or event.

    I also agree to release and hold harmless Beyond Differences from and against all actions, claims, demands, lawsuits, damages, losses, expenses and liabilities of every kind or nature, including but not limited to reasonable attorney’s fees, arising out of this activity, or arising out of or any use of the recording.

    I understand this Form contains the entire agreement and understanding between Beyond Differences and me and may not be amended. I further understand that the laws of the State of California govern this form.

    I understand that Beyond Differences (a nonprofit corporation) with offices at 711 Grand Ave. Suite 200, San Rafael, CA, and its successors have permission and irrevocable absolute royalty-free right to use, adapt, modify, reproduce, distribute, publicly perform and display Released Matter, in whole or in part, individually or in conjunction with other materials for any purpose whatsoever, throughout the world, including but not limited to the purposes of producing and marketing whether that be through film, videotape, photographs, quotations, broadcast, cablecast, internet, social media, CD-ROM and any other medium or method now or later developed.
  • Student Name
  • Parent or Guardian Signature
  • Please type your name here.
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  • Parental / Guardian Consent to Participate in Beyond Differences Research

    During the current 2019-2020 school year, Beyond Differences may seek your child’s feedback on his/her experience in our program to help improve programming efforts. As a youth-led organization, we highly value and continuously seek to learn from our youth participants’ input.

    If you are the parent or legal guardian of a child who may participate in Beyond Differences this school year, your permission via this form is required for us to be able to include your child in our research process to help inform the organization’s planning and decision-making.

    Below are more details, followed by a section seeking your consent.

    DESCRIPTION: With your permission, your child may be invited to participate in ongoing program evaluation to better understand how Beyond Difference’s programming is being implemented, how its programming is perceived and experienced by participants, and how its efforts may be improved.

    She/he/they may be asked to participate in a focus group and/or asked to complete a short survey during a regularly scheduled meeting time with Beyond Differences. This program evaluation values and appreciates your child’s open and honest perspective – there are no ‘right’ answers.

    Please note that your child’s individual privacy would be protected, and his or her anonymity would be maintained in all informal and formal publications and communications resulting from the study.

    Your decision whether or not to allow your child to participate in this research/feedback process is completely voluntary and will not affect his/her participation in Beyond Differences programs or activities. Furthermore, if you give your permission for your child to participate in this survey or focus group research, please understand his/her participation is voluntary and s/he has the right to discontinue participation at any time. S/he also has the right to skip or refuse to answer particular questions.

    PLEASE INITIAL EACH OF THE FOLLOWING THAT YOU PERMIT:
    I give consent for my child to participate in an anonymous feedback survey about his/her experience with Beyond Differences.

  • This parent consent form expires one year after the date of signature. If you have any questions, please contact our organization at beyonddifferences.@gmail.com
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