Health History. Please describe any medical conditions, including all allergies and current medication, that may affect your youth’s ability to participate in the Program. Please list medication and dosage of any medication your youth may need to take during his/her participation in WBHN programs. Please indicate if your youth carries an EPI-PEN or asthma inhaler.
PERMISSION AND WAIVER
By sending the form above, I, the youth’s parent or legal guardian, agree that:
Permission. I grant express permission for my youth to participate in the Program. I understand that my youth may be excluded from participation if he or she does not comply with WBHN’s safety rules and directions.
Permission for Transportation. I authorize WBHN staff and volunteers to transport my youth in vehicles to Program sites if required for his/her participation in the Program.
Awareness and Assumption of Risk. I understand that my youth’s activities in the Program have inherent risks that may arise from the activities themselves, my youth’s own actions or inactions, the actions or inactions of WBHN, its directors, officers, employees and agents, volunteers, and others present at the program, transportation to and from Program sites by WBHN staff and volunteers and dangers and conditions at Program sites. [CONSIDER NEED FOR FULLER DISCLOSURE] I assume full responsibility for any and all risks of bodily injury, death or property damage caused by or arising directly or indirectly from my youth’s presence at Program sites or participation in the Program, regardless of the cause.
Waiver and Release of Claims. In consideration for my youth’s participation in the Programs, I waive and release any and all claims against WBHN, its directors, officers, agents, members, employees, volunteers, and affiliates (collectively, the “WBHN Parties”), for any liability, loss, damages, claims, expenses and attorneys’ fees resulting from death or injury to my youth or property, caused by or arising directly or indirectly from my youth’s presence at Program sites or participation in the Program, regardless of the cause and even if caused by negligence, whether passive or active. I agree not to sue any of the WBHN Parties on the basis of these waived and released claims.
Medical Care Consent and Waiver. I authorize WBHN to provide to my youth first aid and, through medical personnel of its choice, medical assistance, transportation, and emergency medical services. This consent does not impose a duty upon WBHN to provide such assistance, transportation, or services. In addition, I waive and release any claims against the WBHN Parties arising out of any first aid, treatment or medical service, including the lack or timing of such, made in connection with my youth’s activities in the Program.
[Indemnification. I will defend, indemnify, and hold the WBHN Parties harmless from and against any and all liabilities, losses, damages, claims and attorney’s fees that may be suffered by any WBHN Party resulting directly or indirectly from my youth’s presence at Program sites or participation in the Program, except and only to the extent the liability is caused by the gross negligence or willful misconduct of the relevant WBHN Party.]
[Publicity. I consent to the use by WBHN of my youth’s image, voice, name and/or story in any format, including video, print or electronic (collectively, the “Materials”), as WBHN may deem appropriate to promote its programs. WBHN may make the Materials available at its discretion to third parties, on WBHN’s website, in WBHN’s publications, or through any other media, including social networking websites. I waive any right to inspect or approve the finished product or to receive any payment. I grant to WBHN all copyrights in the Materials and waive any legal claims, including those relating to copyright, or rights of publicity or privacy.]
General Provisions. This is the final, complete and exclusive agreement between WBHN and me and supersedes all prior or contemporaneous communications or understandings, either oral or written. This agreement will be binding to the fullest extent permitted by law. If any provision of this agreement is found to be illegal, invalid or unenforceable, the remaining terms will be effective.
I have read this agreement and understand its terms and that I am giving up certain legal rights by signing it. I sign it freely and voluntarily.