SCPL Teen Library Advisor Program Permission Form

Name of Teen Advisor:

Date of Birth: 

Name of Parents/Guardians:

Emergency Contact: 

Relationship of Emergency Contact to Minor: 

Emergency Contact Phone Number: 

Emergency Contact E-mail Address: 

I understand that my child has been selected to participate in the Smyth County Public Library’s teen library advisor program and I authorize library staff and trustees to communicate with my child for the purposes of this program.  I also give permission for library staff or trustees to transport my child to and from board meetings or other program events if necessary.  I authorize the Smyth County Public Library to take photographs and video of my child during their participation in the teen advisor program and to use those images in social media or other promotional media.  I understand that my child has an obligation to adhere to the SCPL patron privacy policy and to respect the privacy of SCPL patrons during their participation in this program. 

My child has the following medical or health issues (including allergies):

My child takes the following medications under the supervision of a physician: 

I authorize SCPL staff or trustees to obtain emergency medical treatment for my child if necessary.  I agree to inform SCPL staff if any new medical issue arises during the period of my child’s participation in the teen advisor program.

To support the participation of my child in the SCPL Teen Library Advisor program, the undersigned parent or guardian agrees to indemnify and hold harmless the Smyth County Public Library, its officers, directors, employees, agents, and assigns (collectively, “Indemnitees”), from and against any and all claims, actions, suits, proceedings, costs, expenses, damages, and liabilities, including reasonable attorney’s fees, arising out of, connected with, or resulting from any act or omission of the Smyth County Public Library, its agents, employees, or contractors, whether negligent or not, in connection with their participation in the Smyth County Public Library’s Teen Library Advisor Program. 

The undersigned parent or guardian further releases, waives, and discharges the Indemnitees from any and all liability, claims, demands, actions, or causes of action whatsoever arising out of any damage, loss, or injury to the parent or guardian’s child, or their property, or both, whether such loss, damage, or injury results from the negligence of the Indemnitees or from any other cause.  This release shall be binding upon the parent and/or guardian, and child, and any other person making claims for loss on their behalf. 

Signature:

Printed Name:

Date: