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City of Bristol CT

111 North Main Street, Bristol, CT, 06010, US



STEP Program Permission Slip

Acknowledgement of Liability Limitations and Assumption of Risk

By signing this form I agree to give my child permission to participate in the Bristol Police STEP Program.

On behalf of my child, I release, acquit, and discharge the City of Bristol from any and all liability, claims, demands, actions, and causes of action which I, or my representatives, may have by reason of an accident which might occur while engaged in the above mentioned Bristol Police Department STEP Program. As with any activity, I am aware that certain risks of injury may exist. Should an injury or accident occur, I will not hold the City of Bristol or any of its staff, contractors, or volunteers liable, and give my permission for my child to participate.

I agree to support my child’s participation. I understand that I may call the Bristol Police Department directly at (860) 584-3011 if I have any questions regarding the activity, or concerns regarding my child. I understand that I have/my child has the right to be treated with dignity and respect. I understand that my child’s rights to confidentiality are protected under Federal and State Confidentiality Regulations, and that information cannot be disclosed without my consent unless my child’s safety is assessed to be in imminent danger or otherwise provided for in the regulations.

I agree to allow my child to be transported by bus or in the vehicle of the Bristol Youth Services or the Bristol Police Department for the purposes stated above.

Should an injury or accident occur, I grant permission for my child to receive necessary emergency treatment by licensed or certified medical personnel at the nearest medical facility and should be contacted.


Date Picker

Parent/Guardian Name

Child's Name

Child's Address

    Child's Date of Birth

    Photo/Media Release (Optional)

    I agree to allow the Bristol Police STEP Program and persons acting for or through them, the right to use, reproduce, assign, and/or distribute photographs, films, videotapes and sound recordings of my child, for use in materials they may create.

    Parent/Guardian Signature

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