DFarm emergency contact, waiver and medical

Comments

Transcription

DFarm emergency contact, waiver and medical
the
design
farm
Participant’s Name:_____________________ Date of Birth: _____________________
Home Address: _________________________ Home Phone: _____________________ EMERGENCY CONTACT FORM AND WAIVER OF LIABILITY
Emergency Contacts (provide at least one)
Name: __________________________ Relationship: ____________________ Cell Phone: ________________ Name: __________________________ Relationship: ____________________ Cell Phone: ________________ Medical Information:
Medical Insurance Plan: _______________ Plan ID#:____________ Phone: ________________ Name of Primary Doctor: ______________________ Phone: _____________________ Name of Dentist: ______________________ Phone: _____________________
By signing below:
• I authorize DFarm to obtain emergency medical care for my child. Any expenses incurred in obtaining such medical care will be paid by me. • I give permission for my child to participate in all program activities. I understand this may include use of hammers, nails, handsaws, screwdrivers, screws, awls, hot glue guns, sewing needles, pins, and scissors. I understand that some materials used at DFarm are donated, and while DFarm makes its best effort to screen all materials, hazards may exist. I understand that participation in DFarm activities may also include visits to nearby parks and surrounding buildings. • I understand that no portion of the tuition will be refunded if the child is absent, withdrawn, suspended, or should otherwise fail to complete the session.
• I give permission for my child to be transported out of the DFarm classroom in case of emergency. • I give DFarm the absolute rights and permission to publish and/or copyright photographs taken of my child during any DFarm sessions. These photographs may be used for the following purposes: website, marketing materials, books, and other publications of DFarm. Photographs may be used without compensation to me or my child, and I hereby waive any right to inspect or approve the finished product, including written copy, that may be created in connection therewith, or the use to which it may be applied. • I do hereby release, waive, discharge, and covenant not to sue DFarm, its officers, employees, and agents for liability from any and all claims including the negligence of DFarm its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in any sessions. Parent/Guardian Name: _____________________Parent/Guardian Signature: __________________________
Date: ______________________

Similar documents