Consent Form

Dear Parent/Guardian,

Bedford County Shop With A Cop (SWAC) is a memorable relationship building experience between local law enforcement and the children of Bedford County. SWAC provides previously nominated, Bedford County children with an opportunity to be paired with local law enforcement to shop for themselves and family members during the holiday season.

Your child has been nominated by a recognized agency within Bedford County to attend the event in December of this year. Depending on Covid-19 state mandates and regulations this December, you, or a guardian, will bring your child to the Walmart in Everett. Your child will be partnered with a law enforcement representative who will provide a once in a lifetime opportunity to shop for themselves or their loved ones. Once complete the child will meet with you, or a guardian, in the Walmart parking lot.

This event is a once in a lifetime opportunity for all parties involved. To apply for your child’s participation, we require that the below written consent form be submitted as soon as possible. If selected, you will be contacted by a representative from our agency prior to the event to confirm your child’s attendance, ensure that all medical issues are documented and to provide a chance for any last minute questions you or your child may have.

It should be noted that any items purchased during the event CANNOT BE RETURNED and any individual caught attempting to return these items for store credit WILL be prosecuted and charged with theft by deception.

Bedford County SWAC is partnered with Altoona First Bank and is endorsed by Your Safe Haven, Inc. and United Way of Bedford County, a non-profit 501 (c) (3).

Consent Form

"*" indicates required fields

Child's Name*

First Last

Child's Age*

Parent/Guardian Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Written Consent:
I do hereby provide written consent of my child, who is under my legal care, to attend the Bedford County Shop with A Cop event.

Printed Name*

Signature*

Date*

Assumption of Risk and Image Release Form
I do hereby fully release and discharge Shop With A Cop and United Way of Bedford, its employees and volunteers from any and all claims from injury, damage or loss which I, my child and/or my property may incur as a result of their participation or attendance in the Bedford County SWAC event. Additionally, I give my permission for my child to be photographed and/or videotaped during their participation and for photographs to be used on social media and or future advertising/promotion of the event.

Printed Name

Signature

Date

Does your child have any medical concerns or dietary restrictions?*

Yes

Please list any dietary/medical restrictions for your child below:*

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Phone

This field is for validation purposes and should be left unchanged.

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