PARENTAL CONSENT & MEDIA RELEASE FORM
Dear Parent/Guardian,
Your child (the “Participant”) has applied to The Junior Academy (the “Program”). In order for your child
to be accepted to the program, we are writing to inform you about the Program and seek your consent
for your child to participate. The Program is a commnity of passionate students, STEM experts, and
companies around the world dedicated to designing innovative solutions to global challenges. Each year,
the New York Academy of Sciences (the “Academy”) invites students ages 13‐17 to join the Program.
Acceptance to the Program allows the Participant to gain access to exclusive educational opportunities
and a remarkable global STEM network through Launchpad, the Academy’s own virtual collaboration
platform. Students develop advanced research, innovation, and collaboration skills with the best‐in‐class
learning resources and leverage these skills to compete in challenges sponsored by industry‐leading
companies.
The Program will take place on Launchpad and participation is subject to the following rules:
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All individuals must be between the ages of 13‐17 with birth dates falling in this range: May 1st,
2007 through February 1st, 2012 for the Spring 2025 Challenge Cycle.
•
All participants must sign up on Launchpad and agree to the Terms and Services and must
submit a valid, signed Parental Consent & Media Release Form before the Program begins.
•
Challenge materials and solutions must be submitted in English in order to be considered.
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Participants can work in teams or individually. Teams can be as large as 6.
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Please be advised that
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the Program, the Participant may have submitted or may later
choose to submit, materials to the Academy of various kinds, whether in hardcopy, electronic, or other
formats or media, such as survey responses, photos, and or other content or information (“Materials”),
in conjunction with the Program. By signing this release, you the Parent/Guardian of the Participant,
acknowledge and agree that:
1. The Materials may include Participant’s image, words, name, and any information the
Participant may present in the Program;
2. The Academy may reproduce, distribute, perform, display, make derivative works of and
otherwise use the Materials without payment, in any format or medium and for any purpose, at
its discretion; and
3. Your grant of rights in this release is irrevocable, perpetual, and assignable
The Academy acknowledges that it will make reasonable efforts to provide attribution to the
author/creator when disseminating whole or part of a lecture, speech, discussion, presentation, or other
public appearance. You may opt out of the media release at the bottom of this form.
If you have any questions regarding the Parental Consent Form/or the Media Release Form, please
contact EDUCATION@nyas.org. Thank you!
ACKNOWLEDGEMENT
In consideration for receiving permission from the Academy for my child (named below) to participate in
the Program described above, I agree as follows:
1. I represent that I am the parent or lawful guardian of the minor child named below.
2. I agree to be responsible for directing and causing my child to adhere strictly to all applicable
rules, regulations, policies, guidelines, and instructions of the Program, including those
concerning safety, general decorum, and conduct. See Terms of Use, Code of Conduct,
Intellectual Property Policy, and Privacy Policy.
3. I acknowledge that my child’s participation in the Program could expose my child to adults over
the age of majority who are also participating in the Program as mentors and experts.
4. I agree and understand that I am responsible for the actions of my child. I release discharge, and
hold harmless the Academy, and their respective sponsors, charitable sources, officers,
directors, staff, agents, and employees to the fullest extent permitted by law, from any and all
claims and liabilities, including claims for negligence or gross negligence, which may arise in
connection with the Program, except those that may arise due to the intentional wrongdoing of
the Academy’s officers, directors, staff, agents, or employees.
The Parental Consent & Media Release Form shall be governed by and constructed and interpreted in
accordance with the laws of the State of New York, USA, without regard to conflicts or choice of law
rules or principles. All legal actions and proceedings related in any way to the event or this Parental
Consent & Media Release Form shall be brought exclusively in the federal or state courts sitting in the
State of New York, USA, and I will waive any objection to jurisdiction and venue in such courts.
I hereby give my permission for my child name below to participate in the Program on terms and
conditions stated above. By signing below, I confirm that I have fully informed myself of the contents of
this Parental Consent & Media Release Form by reading it before I signed it, and I have signed and
entered into it voluntarily.
Name of Participating Child
First Name
Last Name
Email of Participating Child
Name of Parent/Guardian
First Name
Last Name
Email of Parent/Legal Guardian
Date of Consent
Month Day
Year
Signature of Parent/Guardian
Refusal of Permission (Media Release)
I do not give permission for my child’s image to be used in the conditions stated above.
ONLY SELECT IF YOU ARE REFUSING PERMISSION.