Parent/Guardian and Participant Release Statement Fillable
If my child has medical conditions, which may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number listed
below. If I cannot be reached, I hereby authorize
to make a decision on my behalf. If there are any activities I do not want my child to be involved in, I have listed them below. I understand and hereby agree to assume all of the risks, which may be encountered on said activity, including activities preliminary and subsequent thereto.
I do hereby agree to hold Genesis Hopeful Haven, and its agents employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arises in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the State of Florida and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.
I further state that I have carefully read the foregoing student information and behavior code, the parent/guardian and participant release and know the contents thereof and I sign this agreement and release as my own free act. This is a legally binding agreement which I have read and understand.
Participant’s Name (Printed):
Date:
Parent/ Guardian’s Signature:
Parent/Guardian Name (Printed)
Emergency Contact:
Cell:
Please list the activities you do not want your child to participate in:
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