Prison Awareness Program - Gwinnett County

Scott Riner's Prison Awareness Program

Fields marked are required.

Parent/Guardian's Name:

Participant's Age

Parent/Guardian's Phone Number:

Parent/Guardian's email address:

Children name(s):

Please describe the challenges, including any criminal involvement, you are experiencing with your child:

When is the best time you can be reached?

Application Verification Signature

(Check box to indicate acceptance)

I hereby grant permission to Gwinnett County and its affiliates to photograph or videotape me during my participation in the program. I understand that these photographs or videos may be used for promotional, educational, or other purposes related to the program.

I waive any right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. I also waive any right to royalties or other compensation arising or related to the use of the photographs or videos.

I release, discharge, and hold harmless Gwinnett County, its employees, agents, and volunteers from any and all claims, liabilities, damages, or expenses arising from the use of the photographs or videos, including but not limited to claims for defamation, invasion of privacy, or copyright infringement.

Signature (Enter full name)

Date: 03/12/2026 10:31 PM

Increase font size

Decrease font size

Dark/light mode

Scott Riner's Prison Awareness Program

Application Verification Signature