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Thank you for being part of our FREE Code Dance Create camp at the southern Oregon Coast, August 21-25. It will be held at Winter Lakes High School, 1501 W Central Blvd, Coquille, OR 97423. It is open to incoming grade 3 to grade 8 students.

    Youth Permission and Waiver Form

    Name of Youth Applicant (required)

    Name of Parent or Guardian (required)

    Relationship to Youth Participant (required)

    Home Address (required)

    City, State

    Email Address (required)


    Are you able to provide transportation for your youth? If possible, that's a big help to us.

    If you chose "some days," which days do you need transportation?

    If you need transportation, please share any special instructions. We'll let you know the approximate pickup time.

    Other adults authorized to pickup participant(s)--and their phone numbers:

    Code Dance Create camps are led by veteran educators with decades of experience who will keep participants safe and engaged, including Rick Reynolds, M.S.Ed., Founder of Engaging Every Student, Mindy Chappell, Ph.D. of Portland State University, and Professor Darryl Thomas of Western Oregon University. That said, we need you to read and sign this waiver and release to be able to offer the camp. Please read it carefully before signing.

    I am the parent or legal guardian of Participant named below and I, the undersigned, enter this Release and Waiver of liability and Assumption of Risk Agreement (“Agreement”) on behalf of myself, the Participant, my personal representatives, next of kin, heirs, successors, and assigns and anyone else who may make any claim for or on behalf of the Participant.

    • I will cause the Participant to agree and comply with the terms of the Agreement and not to take any actions that would assist or cause the Participant to invalidate, renounce, negate, revoke, or disclaim any part of the Agreement.

    • I make this Agreement for the benefit of partner organizations, other Participants, camp coordinators, sponsors, suppliers, supporters, and all private and public parties whose property the camp described above may be located (collectively the “Released Parties), including, without limitation, the Released Parties’ employees, agents, personal representatives, next of kin, heirs, successors and assigns.

    • I make this Agreement in consideration of the Released Parties providing Participant with the opportunity to participate in this camp.

    • Participant and I accept full personal responsibility for all risks arising from or relating to this camp.

    • Participant’s involvement in this camp is completely voluntary and neither participant nor I have received nor expect to receive any compensation for participation in it.

    • Participant will read, listen to and follow all safety instructions and procedures presented in conjunction with this camp and use best judgment based upon physical and mental abilities at all times, and to immediately terminate participation in this camp if activities become too strenuous, difficult or hazardous.

    • I agree to waive all liability of the Released Parties, discharge them, and covenant not to sue them for any liability, claims, sums, costs, or other expenses on my account that may be caused in whole or in part by Participant’s involvement in the camp.

    • I agree that this Agreement shall act as a complete bar against all actions or claims that I might otherwise bring against the Released Parties, including negligence claims, arising from or related to this camp.

    • I have read this Agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature. I intend this Agreement to be a complete and unconditional release of all liability to the greatest extent allowed by law, and I further agree that if any portion of this Agreement is held invalid, then the balance of the Agreement shall continue in full force and effect.

    • I understand that a photographer may be present to photograph the activities at the camp and that Participant may be photographed while participating in the camp. I agree that I will email Rick Reynolds at if Participant does not wish to be photographed.

    • I hereby grant the irrevocable and unrestricted right to use and publish photographs of Participant, or in which Participant may be included. Unless I contact Rick Reynolds to ask that photographs of Participant not be used, I hereby release Photographer and their legal representatives and assigns and partner organizations from all claims and liability relating to any such photographs.

    Please type your legal name below to serve as your signature on this agreement.

    Thank you so much for your involvement and we look forward to connecting soon!