By completing this membership application Treasure Box U-S and I, the primary parent/guardian of the participant named above, agree to the followning:

1. I understand that my child’s picture/video may be taken for media and/or public relations and allow for these
representations to be used for media and/or public relations purposes unless I submit a statement to the contrary to appropriate Treasure Box U-S staff.

2. I give permission for my child to be transported by Treasure Box U-S to all field trips and pickups from school. I understand that transportation is dependent on my child’s good behavior on the van.

3. I understand that the Treasure Box U-S is not responsible for lost or stolen items.

4. I acknowledge that I have received a copy of Treasure Box U-S Handbook and understand that my child is expected to follow all rules.

5. I understand that Treasure Box U-S has an open door policy. It is my responsibility to make sure my child knows how to get home at the end of the night.

6. I give permission for Treasure Box U-S to survey my child about his or her experience, behaviors, skills, and attitudes. All information provided to TB U-S will be kept confidential.

7. I, on behalf of my child, waive and release Treasure Box U-S, and its employees, officers and directors from any and all claims, caused by action, injury and damages that have been or may be incurred by my child as a result of
his/her membership, activities and travel as part of Treasure Box U-S participation. I understand that this is a waiver of my possible rights and those of my child and is knowingly and freely made. No promises or other
inducements have been provided to secure this waiver and release.

8. As the legal parent/guardian of this child, I authorize the School District and/or the educational institution my child attends to release the following information to the Treasure Box U-S on a quarterly basis: grade point averages, photocopies of report cards, school attendance rates, grade advancement information, behavior plans, graduation
information and any other information regarding the educational and socio-emotional well-being of your child. This is valid unless I submit a statement to the contrary to appropriate TB U-S staff. Photocopies of this form shall be considered a valid release for all information.

9. I verify that the information on this form is correct.