Activity/Photo/Video Waiver Release Of Liability

Big Hearts Activity/Photo/Video Waiver Release of Liability and Medical Authorization Form 

Form must be signed by each parent or guardian before participation in any/all Big Hearts Activities.

GENERAL INFORMATION:  

Participant’s Name_______________________________________ DOB_________________ 

Address_______________________________________________ Phone________________ 

City__________________________, State_____ Zip___________ 

Physician______________________________________________ Phone________________ 

Physician Address__________________________________________________

List any allergies (food, drug or otherwise) or medical history: _____________________________________

Parent/Guardian email address: ____________________________________

ACCIDENT WAIVER AND RELEASE OF LIABILITY  

I hereby assume all of the risks of participation, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault. 

 I certify that my child is physically fit, have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event.  I acknowledge that this Accident Waiver and Release of Liability Form will be used by Big Hearts Day Habilitation Center for the activity or event in which the client may participate, and that it will govern my actions and responsibilities at said activity or event. 

 In consideration of the application and permitting the client to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: 

• I waive, release, and discharge from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this center/event, The following Entities or Persons: Big Hearts Day Habilitation Center.
• I indemnify hold harmless, and promise not to sue the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by negligence of release or otherwise.

I acknowledge that this activity or even may involve a test of a person’s physical or mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to participants, or teacher of the event, and lack of hydration. 

 I understand that as this event or related activities, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by Big Hearts Day Habilitation Center.

 The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. 

 Big Hearts Day Habilitation Center

The undersigned parent and natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward’s participation in the activity or event, and has agreed individually an on behalf of the child or ward to the terms of the accident waiver, release of liability and medical authorization set forth above. 

I certify that I have read this document, and I fully understand its content. I am aware that this is a release of liability/medical authorization and a contract and I sign it of my own free will. 

 Name of Participant (Please Print):

 _________________________________________________________________________________

Signature of Parent or Guardian:

 _________________________​     Date ____________________________

 Photo/Video Consent to Release Form

I hereby give permission for images of my child, captured during the classes through video, photo, phone and digital camera et al, to be used solely for the purpose of the Big Hearts Program promotional material and publications, and waive any rights of compensation or ownership thereto. 

 Name of Participant (Please Print):

 _____________________________________

Signature of Parent/Guardian/Participant (over 18):

 

_________________________ 

 

Date​   ________________________________________