LG Dream Consent Form



Parental Consent & Release Form

Dear Parent/Guardian,                                                Date: ________________________


Please sign and return the following form to Fam Moulton: Fam@nextstepcarpet.net.


I give permission for my daughter, _________________________________________, to attend and participate in the activities of Dream It, Be It: Career Support for Girls, a program of Soroptimist International of the Americas/LiveYourDream.org. I agree to the following, intending for me and my child to be legally bound:


  1. In case of medical emergency, I grant the facilitators the right to authorize medical care, if I cannot be promptly and readily reached.


  1. In the event medical treatment is necessary for my child, I agree to pay all costs associated with such treatment including the cost of emergency medical evaluation and care. I further agree to hold harmless and indemnify Soroptimist/LiveYourDream.org and its volunteers for any costs associated with medical treatment and transportation for my child.


  1. I agree that Soroptimist/LiveYourDream.org is not responsible for any bodily injury, illness or disease, or loss or damage from any cause concerning this program, even in the event of negligence by the club, its members or facilitators. I release and agree to hold harmless Soroptimist/LiveYourDream.org members and facilitators from any liability in connection with the activities of this program.


  1. This consent and release shall be governed by the law of the state in which Soroptimist/LiveYourDream.org La Grande, OR is located, without regard to its principles on conflicts of laws.



Parent/Guardian Name:  _________________________________________________________________________


Parent/Guardian Signature:  _____________________________________________________________________


Parent/Guardian Home Phone: __________________________________________________________________


Parent/Guardian Work Phone: ___________________________________________________________________


Parent/Guardian Cell Phone: _____________________________________________________________________




Media Consent Form

Dream It, Be It: Career Support for Girls participants have great stories to share about this life-changing program! Girls often share what they learned, how it prepared them to pursue their career goals, and how it boosted their confidence. So many girls have had positive experiences! When promoting Dream It, Be It, Soroptimist & LiveYourDream.org use first-hand stories and testimonials to show the program’s impact, encourage volunteers to host projects in their communities, and to attract donors so that we can continue providing resources to support this program.

By signing this media consent form, you give Soroptimist & LiveYourDream.org permission to use the below-mentioned girl’s name, photo, likeness and/or voice for publicity purposes in various formats including, but not limited to, print media, social media, photographs, website, audiovisual, fundraising appeals, ads, etc. Soroptimist & LiveYourDream.org shall retain all rights to said materials.

Name (print)   ___________________________________________________________________________

If above person is under 18 years of age:

Parent/Gaurdian Name (print)    ___________________________________________________________________________

Signature   ___________________________________________________________________________

Address   ___________________________________________________________________________

City, State Zip   ___________________________________________________________________________

Phone    ___________________________________________________________________________

E-mail   ___________________________________________________________________________

Date   ___________________________________________________________________________

Witness Name (print) ___________________________________________________________________________

Signature                  ___________________________________________________________________________

Date                         ___________________________________________________________________________