Participant Name *
Age * Does the participant receive services at Children's Clinics? * Parent/Guardian Information *
Relationship to Participant * Primary Phone Number * Parent/ Guardian Preferred Email *
* Emergency Phone * Emergency Contact First and Last Name *
Please identify an individual other than yourself that we can contact in case of an emergency.
Will the participant need 1:1 assistance or are they able to participate independently? * Please identify any behaviors or special needs and provide our staff members with ways you feel they can best help your participant enjoy their experience with us: * Please list any allergies (food or environmental), Limitations/Restrictions (Activity or Diet): * Why does this class interest you and what do you hope to learn? * Would you like to apply for a scholarship? *
If yes, please email firstname.lastname@example.org to apply.
My child has permission to (select all that apply; for 13+ participants, only) * I am able to attend all 6 sessions of the series * If you are not able to attend all six sessions, how many sessions are you able to attend? * Please check that you have read and agree to the following: *
I authorize my child to participate in Children’s Clinics Childhood Experiences Programs. I acknowledge the risks inherent in the participation by my child. In my absence, I further authorize the staff representing Children’s Clinics to act for me according to their best judgment in any emergency requiring medical attention for my child and I hereby waive and release those staffers, and volunteers of Children’s Clinics from all liability for any injuries or illnesses, that may be incurred while participating in Children’s Clinics Childhood Experiences, while in attendance, except for injury directly resulting from gross negligence or willful misconduct.
Please check that you have read and agree to the following: *
COVID-19 Waiver of Liability:
I also authorize my child to participate in Children’s Clinics Childhood Experiences during the COVID-19 pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not without a test to confirm. I understand that due to the inherent nature of exercise, sports, and group events, and based on the evolving knowledge of the virus, my child has an elevated risk of contracting the virus simply by participating. I understand that my child contracting the virus may place others he or she comes in contact with at risk for contracting the virus as well. I confirm that I will not send my child to the program if my child or anyone from their household are known to be carrying the virus or have any of the following symptoms of COVID-19: • Fever • Shortness of Breath • Dry cough • Runny Nose • Sore Throat • Diminished sense of smell or taste. I also understand the CDC recommends social distancing of at least 3-6 feet, but this will not be possible for the entire duration of Children’s Clinics Childhood Experiences Programming. In an effort to mitigate risk, Children’s Clinics staff and volunteers will wear a mask and it is required that all participants and adults accompanying the child wear a mask that covers both their nose and mouth. I understand that while Children’s Clinics staff and volunteers will follow mitigation procedures to reduce risk, a risk still remains. As the parent/guardian, I agree to assume all risks and hazards associated with my child’s participation, including the risks associated with the COVID 19 pandemic. To the fullest extent permitted by law, I agree to waive, release, and discharge any and all claims against Children’s Clinics. I have read, understand, and accept the COVID-19 Expectations and Waiver of Liability.
Please check that you have read and agree to the following: * Please check that you have read and agree to the following: *
I consent to the photographing/video recording/ audio recording of the above-named patients by Children's Clinics staff at this event. I agree the resulting images or recordings may be used for Children's Clinics publicity or marketing purposes (brochure, pamphlet, lobby display, social media posts, printed material, etc.). I understand that I have the right to reverse this consent, in writing, at any time before the image or recording is used for the purposes indicated above.