Confidentiality:
Any confidential information requested is for our records and for the funding our organization receives. The answers you provide will be kept strictly confidential. Your cooperation in providing this information is both appreciated and necessary. I/We authorize the Norris Square Community Alliance to have and use photographs, slides, moving pictures or television videotapes of the individuals named on this application as may be needed for its record or public relations program. I/We acknowledge that all the above information is accurate and that my decision to participate in the program is completely voluntary. I/We also agree that in the event that any information changes during the time of my/our participation at Norris Square Community Alliance, that I/We will inform the facility immediately.
I, {name} the parent/guardian (head of household) on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Norris Square Community Alliance, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the facilities.
Data Collection
I give my permission to the Norris Square Community Alliance to collect information via online or written surveys, questionnaires, interviews, and focus groups for all the household members on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with organization staff, funders, and other community stakeholders to evidence program effectiveness and/or organization impact on our clients.
Photo Release
- I hereby grant Xiente, Inc. the right to use my image in photographs, videos, or other digital media ("media") in all its publications, including online platforms, without any compensation.
- I understand and agree that all media containing my likeness will become the property of Xiente, Inc. and will not be returned to me.
- I irrevocably authorize Xiente, Inc. to modify, reproduce, display, publish, or distribute these media for any lawful purpose. I also waive any rights to review or approve the final product where my likeness is included, as well as any rights to royalties or other compensation related to the use of the media.
- I hereby release and forever discharge Xiente, Inc. from all claims, demands, and causes of action that I, or my heirs, representatives, executors, administrators, or any other individuals acting on my behalf or on behalf of my estate, may have now or in the future as a result of this authorization.
- I confirm that I have read and understood this Photo Release. I affirm that I am at least 18 years old. If I am under 18 years old, I have secured the necessary consent from my parents or guardians, as indicated by their signatures below.