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651 N Brightleaf Blvd

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AUTHORIZATION AND CONSENT OF PARENT(S) AND RELEASE OF LIABILITY

Child's Information

Medical History

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AUTHORIZATION AND CONSENT OF PARENTS

I do hereby state that I have legal custody of the minor. I grant my authorization and consent for Children's Unlimited Academy, LLC authorized adult ("Designated Adult") to administer general first aid for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and to treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the Designated Adult in the exercise of his/her best judgment upon the advice of any such medical or emergency personnel.

I also understand and agree that my child's participation in outside play and other activities involves the risk of injury and even death from various causes, including but not limited to accidents, fall, strenuous physical activity, dehydration, collision, weather, equipment defects, and negligence. On behalf of my child, I assume these risks. I hereby release, discharge, and hold harmless and indemnify, and covenant not to sue, Childrens Unlimited Academy and/or its representative including staff, employees, trustees, and volunteers.