All potential youth members under 18 must obtain parental permission before any training can begin. You must be with someone over 18 who is in a supervisory capacity.
Please print out this form, fill in the form completely, sign where indicated and return this form to:
Valley Free Radio
140 Pine St.
Florence, MA. 01062
Name of youth member (under 18): ______________________________________________________
Parent /Legal Guardian Name: ___________________________________________________________
Address______________________________________________________________________________
Home Phone ____________________________ Cell Phone________________________________
Valley Free Radio, known as WXOJ-LP 103.3FM-Northampton,MA. is a
community radio station operating under FCC license. The person named above is under 18
and has applied for training to host a program for broadcast on WXOJ. Program Hosts
are responsible for the content of their shows and are subject to the rules and regulations of the station and
the Federal Communication Commission.WXOJ is run entirely by volunteers. WXOJ provides no
transportation or reimbursement for services rendered by the member requesting training.
As the parent or guardian of the minor, your written approval is required to allow the following:
1. To attend training at the studio towards a program host on WXOJ.
2. To work as a program host during certain hours per applicant request, subject to current and
future rules of the station. Parents/guardians may restrict those hours in the space provided
below. If left blank, you consent to your child being at the station without time limitation. If a
requested time for a student falls during regular school hours, an additional approval form from
the sending school will also be required before any show time will be granted.
As parent/guardian, I authorize the participation of the youth member listed below in the activities of the
station. I accept responsibility and agree to indemnify Valley Free Radio for any actions taken that are in violation of any law or municipal code or in violation of regulations set forth by the FCC with regard to broadcasters. I further agree to assume financial responsibility for damages caused by the person listed, if deemed to be through negligence or in willful violation of rules set out by Valley Free Radio.
Agreed & Accepted by:
_________________________________________________________________
Name Date
Parent or legal guardian for:
_____________________________________________________________________
Name Birth Date
Permission granted to volunteer, train or host a program during the hours listed below:
WEEKDAYS
From————————-To
WEEKENDS
From————————-To
Please print out this form, fill in the form completely, sign where indicated and return this form to:
Valley Free Radio
140 Pine St.
Florence, MA. 01062