Connection - Participant Registration Form

First Name

Last Name

Date of Birth

Country

Parent/Legal Guardian_

Alt Email

Username*

Password*

Confirm Password*

Address Fields

The address information you provide will be used for verifying your identity and personalizing your experience on our platform. We ensure the confidentiality and security of your address details in compliance with our privacy policy.

Address

Address Line 1

Address Line 2

Landmark

City

State or Region

Zip

Contact Information

Your contact information will be used for account-related communications and to keep you informed about updates and important notifications. We value your privacy and will not share your contact details with third parties without your consent.

Phone Number

Alt Phone Number

T-Shirt (Select one)

Emergency Contact Information

Emergency Contact

Relationship to Participant

Content and Release

Terms and Conditions

Terms and Conditions

Acceptance of Terms
By registering on this platform, you agree to comply with and be bound by the following terms and conditions. Please review them carefully. If you do not agree to these terms, you should not register or use this site.

User Information
You agree to provide accurate, current, and complete information during the registration process and update such information to keep it accurate, current, and complete. You are responsible for maintaining the confidentiality of your account and password.

Privacy Policy
Your privacy is important to us. Please refer to our Privacy Policy for information on how we collect, use, and disclose your personal information. By registering, you consent to our collection, use, and disclosure practices, and other activities as described in our Privacy Policy.

User Conduct
You agree not to use the platform for any unlawful or prohibited activities. You also agree not to interfere with the security, functionality, or proper working of the platform. This includes, but is not limited to, uploading or sharing harmful or malicious content, spamming, and unauthorized access attempts.

Intellectual Property
All content on this platform, including but not limited to text, graphics, logos, and software, is the property of the platform owner or its content suppliers and is protected by copyright, trademark, and other intellectual property laws. Unauthorized use of such content is prohibited.

Limitation of Liability
In no event shall the platform owner be liable for any direct, indirect, incidental, special, or consequential damages resulting from your use or inability to use the platform, including but not limited to damages for loss of profits, data, or other intangible losses.

Modifications to Service
We reserve the right to modify or discontinue the platform, temporarily or permanently, with or without notice to you. You agree that we shall not be liable to you or any third party for any modification, suspension, or discontinuance of the platform.

Termination
We reserve the right to terminate or suspend your account and access to the platform at our sole discretion, without notice and liability, for conduct that we believe violates these terms or is harmful to other users of the platform, us, or third parties, or for any other reason.

Governing Law
These terms and conditions are governed by and construed in accordance with the laws of the jurisdiction in which the platform owner operates. You agree to submit to the exclusive jurisdiction of the courts located in that jurisdiction for the resolution of any disputes.

Contact Information
If you have any questions about these Terms and Conditions, please contact us at [Contact Information].

Check this box to agree to our terms and conditions and privacy policy.

Signature

I, ___________________________ hereby grant permission for the Participant to take part in the Grassroot Connections Mentor Program which is sponsored by the Grassroot Connections, Inc. I also agree,on behalf of myself and the participant, not to make any claims or demands of any kind against Grassroot Connections or any of its volunteer or agents for any loss or injury that the participant might sustain while engaged in the said program including transportation to/from the program site. I authorize such physician or medical staff as the Grassroot Connections may designate to carry out any minor medical/ surgical treatment and/or medication necessary, or take the participant to the nearest emergency facility, and I further authorize its medical staff to provide any treatment deemed necessary for the well-being of the participant.

I also agree that photographs of the participant may be taken and published for the purpose of publicizing and promoting programs operated and /or sponsored by the Grassroot Connections.

Permission Granted

Connection – Participant Registration Form