democratic Classroom Leadership Summer Institute July 31 – Aug 4, 2023 (in-person)

First Name: *

Last Name: *

Personal Email: *

Work Email Address: *

Mobile Phone Number: *

School/Institution/Organization Name: *

School/Work Phone: *

Job Title: *

Subject/Grade Level(s): *

Gender (Optional): Male Female Other

Ethnicity (Optional): American Indian Black Hispanic/Latino White Asian Native Hawaiian or other Pacific Islander Other (please specify below)

Ethnicity (Other):

If you are using a Coupon Code, please enter it here (you will be asked again at Checkout):

How did you find out about this workshop?: *

RELEASE OF LIABILITY & PARTICIPANT AGREEMENT & MEDIA PHOTO RELEASE 1. Informed, Voluntary Decision: I have made an informed and voluntary decision to participate in a FCLC program. I understand that it FCLC is a social justice organization committed to undoing racism, sexism and other oppressions and that I may be asked to explore my own internal biases and blind-spots around them which I may find personally and emotionally challenging. I understand that FCLC is committed to participants exploring avenues to personal transformation and that this may be personally and emotionally challenging. (Please enter your initials below): *

2. Use of Image/Media Release: I give permission for FCLC to use my picture and image(s) derived therefrom in any form, should picture(s) of me be taken during or in connection with any FCLC activity or event. I hereby consent to allow FCLC to use recordings of my voice and/or video of me made during any FCLC event for broadcast and non-broadcast distribution of any radio, television, web (internet), print or other media program for the purpose of promoting FCLC and its work. I hereby release FCLC, and its partner organizations, and media representatives from any and all claims, demands, actions, causes of action of every name and nature which I might have against them as a result of such a broadcast, news article, television program, or web feature. (Please enter first and last name below): *

Use of Image/Media Release: * I give my consent. I do not give my consent.

3. Conduct: I understand that for my health and safety (emotional and physical) and that of other participants and FCLC staff, requires that the rules and regulations it establishes be observed. I understand that I am responsible for exercising caution and common sense at all times to avoid injuries and to avoid disruptions and/or negative emotional and physical impacts on others and on FCLC programs. My main priority is my own safety and the safety of any other FCLC participants and FCLC staff. I agree to act with the intention of furthering FCLC’s positive mission. To do otherwise would result in termination of my participation with FCLC.: * I have read and understand.

4. Attendance: Because of the importance building community in this work, I agree to be on time and attend 100% of the full program. If an emergency arises, I will communicate it to FCLC staff immediately.: * I have read and understand.

5. Use of Cell Phones and Technology during Programs: Because of the importance of building community as a cornerstone of this work, I agree to only use cell phones and technology outside the program/workshop space and only during breaks. 
If I am using a laptop to take notes, I will have only the application on which I am taking notes open and all other applications closed.: * I have read and understand.

6. Communication of Possible Personal Negative Impacts on FCLC Programs and Participants/Staff: I will communicate in writing prior to registering for an FCLC program any condition that I have that may interfere with my ability to participate fully and positively in the program. I will also communicate any new condition immediately to FCLC staff if one arises during program.: * I have read and understand.

7. Use of Alcohol and Drugs Prohibited: I will refrain from use of alcohol and/or illegal drugs, and/or prescription drugs for which I do not have a prescription during FCLC educational programs and activities. Note that FCLC sponsors non-educational activities such as “happy hours” during which time there is explicit use of alcohol.: * I have read and understand.

8. Sexual Activity & Harassment - sexual harassment is forbidden I will not participate in any sexual activity with anyone associated with FCLC, including staff, volunteers, participants during FCLC educational activities. FCLC recognizes the right of all participants, staff, and volunteers to work and participate in an environment free of discriminatory intimidation. Sexual harassment of anyone associated with FCLC (participants, staff, volunteers) is illegal sex-based discrimination and will not be tolerated. Sexual harassment is prohibited. If I engage in sexual harassment, I will be face immediate expulsion from FCLC and its programs and may be subject to legal action because of my behavior. Sexual harassment means any unwelcome sexually-oriented practice, comment, look, suggestion, or any unwarranted contact that creates an uncomfortable environment for the person being harassed. Sexual harassment is behavior of a sexual nature that is deliberate and unsolicited. Sexual harassment is coercive and one-sided, and people of all genders can be victims of it. FCLC forbids any unwelcome sexual advances or other verbal or physical conduct of a sexual nature where submission to such conduct is made, either explicitly or implicitly, a condition of employment or a basis for any employment decision. FCLC prohibits such conduct and will not permit it to affect any participant or employment decisions rendered by FCLC.: * I have read and understand.

9. Right to refuse Policy: I understand that FCLC reserves the right to refuse or cancel the participation of anyone at its sole discretion prior or during FCLC programs. I understand that this participant agreement is between FCLC and myself, regardless of how I sign up (whether individually or in a group) and that FCLC reserves the right to ask me to leave. In the event of cancellation of participation, I understand that I am NOT entitled to a refund of any kind. I forfeit any and all payments to FCLC due to the fact that I have disrupted the program and created a negative experience either for other FCLC participants and/or FCLC staff and volunteers. If FCLC becomes aware of inappropriate behaviors after the termination of program(s), FCLC reserves the right to refuse granting credits and/or clock hours. If I received a scholarship for program, I am obligated to pay in full the cost of the program retroactively.: * I have read and understand.

10. Incapacitation: If I become ill, incapacitated, FCLC, its staff and volunteers may take any action they deem necessary for my safety and well-being, including securing medical treatment (at my own expense) and transporting me home or to medical institutions.: * I have read and understand.

11. Changes in Schedules and Program: FCLC has the right to make changes to all aspects of the published schedule and arrangements. FCLC and its employees or agents have the right to cancel or change any element of the program as circumstances require including but not limited to the right to change the faculty, the facilities, and the content. I understand that FCLC cannot be responsible for additional travel costs or expenses that may result from airline schedule changes, delayed or changed arrival or departure times, flight cancellations, natural disasters, crime, weather, illness, or other unforeseen events. I am responsible for all costs and expenses associated with my participation in the volunteer program, including these unexpected or unforeseen costs.: * I have read and understand.

12. Limitation of Control: I understand that FCLC cannot be responsible for the actions of participants, for events that are not part of the program, or that are beyond the control of the FCLC, or for situations that may arise due to failure of a participant to disclose pertinent information.: * I have read and understand.

13. Release from Liability, Waiver of All Claims, Assumption of Risk: I am aware that there are risks involved in participating in FCLC including but not limited to the following: (1) Injuries from movement activities; (2) emotional distress which emerges from sensitive content areas such as racism, sexism, memories from the way our parents raised us, etc. I, on behalf of myself, accept all the risks, including but not limited to the risks listed above, of participating in FCLC activities and the possibility of personal injury and/or emotional distress. I waive any and all claims I may now and in the future have against, and release from all liability and covenant and agree not to sue Full Circle Leadership, LLC and its officers, directors, staff (volunteer or paid), for any personal injury, death, and property damages, expenses or loss sustained by me or us as a result of my participation in any activities sponsored by or associated with FCLC due to any cause whatsoever. Without limitation of the foregoing, if I am signing on behalf of a minor, I agree to hold harmless and indemnify Full Circle Leadership, LLC and its staff from and for any and all claims brought on behalf of the minor.: * I have read and understand.

14. This Participant Agreement & Release Form serves for this specific workshop as well as for all future workshops on into perpetuity. I understand that while FCLC may require that I complete an updated or adapted Participant Agreement & Release Form in the future, this Participant Agreement & Release Form remains valid for the duration of my engagement with FCLC.: * I have read and understand.

15. Severability; Non-Waiver; Arbitration: Should any provision(s) of this document be determined to be unenforceable, such determination shall not affect the enforceability of any other provision(s) hereof. Should FCLC decline or fail to enforce any breach(es) of any provision(s) hereof, FCLC’s doing so shall not be deemed to be and shall not constitute a waiver of its right to enforce any other ensuing breach(es) or any other provision(s) hereof. This constitutes an agreement between FCLC and me with reference to the subject matter referred to herein, and I do not rely upon any promises, inducements, or agreements not stated herein, including but not limited to any oral statements made to me by any agents or employees of FCLC, or any other person associated with FCLC. This agreement may be amended or modified only in writing. This agreement shall be governed in all respects, and performance hereunder shall be judged, by the laws of the State of Washington. Any claim or controversy arising hereunder or relating hereto shall be settled by arbitration before a single arbitrator In Washington in accordance with the Commercial Arbitration Rules of the American Arbitration Association then in effect. The award rendered by the Arbitrator shall be final, and judgment may be entered upon it in accordance with applicable law in any court having jurisdiction thereof in the State of Washington. Notice of the demand for arbitration shall be filed in writing with the other party to the agreement and with the American Arbitration Association in accordance with the Commercial Arbitration Rules of the American Arbitration Association then in effect. The demand shall be made within six months after the claim, dispute or other matter in question has arisen, or shall be forever barred. I have completely read and fully understand this “Release of Liability & Participant Agreement” and unconditionally agree to be bound by and comply with it. Furthermore, I will do my best to uphold the mission of FCLC throughout the entire program in everything that I do. I confirm that I am of full legal age. I have read and understood this agreement prior to signing it and agree that this agreement shall be binding upon me. (Please enter your first and last name as your digital signature below): *