Emergency/Medical Authorization & Waiver form for Minor Participants Please review, complete, sign and return to the Academy Secretary. Each parent or guardian must sign.
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1. EMERGENCY AUTHORIZATION FORM
I/We ___________________________________________ are the parent(s) (custodial parent) or guardian(s) of______________________________, a minor, who is participating at 16 Stones Academy. In the event I/We cannot be reached, I/We authorize the Director of Education or the acting person in charge as well as medical specialists to make decisions regarding the emergency care or treatment of the above mentioned child, including seeking and approving medical treatment for non-emergencies. This Emergency Authorization is valid from __________________ to __________________, the dates of the co-op.
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2. WAIVER OF LIABILITY FORM
In Consideration of the use of certain 16 Stones Academy facilities, the undersigned understands that, as the parent(s) or guardian(s) of the participant, he/she/they is/are assuming full risk of injury arising from the use of these facilities.
Any personal belongings that __________________________________ brings with him/her to 16 Stones Academy is at his/her risk and is not the responsibility of 16 Stones Academy. Further, these items are NOT covered by 16 Stones Academy insurance coverage.
I/We understand and agree that 16 Stones Academy and personnel will provide my/our child with instructions on any limitation to his/her participation. Neither 16 Stones Academy nor any of the personnel shall be responsible for any injury or damage except that caused by the sole negligence of 16 Stones Academy or its personnel.
By signing below I/We expressly agree to be bound by the terms and conditions of this agreement.
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4. WAIVER OF PUBLICITY FORM
I, the undersigned, give permission for the use of any photos, movies, and audio or video tapings of my child's activities at 16 Stones Academy. The material so obtained may be employed with 16 Stones Academy approvals for educational purposes, media coverage or for publicity benefiting education.
_______________________________ _______________________________ ___________ Signature of Parent or Guardian Relationship to Participant Date
_______________________________ _______________________________ ___________ Signature of Parent or Guardian Relationship to Participant Date
