For ofc use:
To the best of my knoweldge, I verify that the above information is complete and accurate.
By checking I agree and submitting this form, you give permission for your child/teen to participate in the Center for Children program, which includes, but is not limited to groups at school, community locations, or Hospice of the Piedmont offices, individual support sessions, and camps.
I agree/do not agree to give permission to Hospice of the Piedmont's counselor(s) to share information via telephone, email, or in person regarding my child with his or her counselor and for my child to be seen by a Hospice of the Piedmont counselor, individually, or in a group at school.
I hereby consent to engaging in grief related telemental health counseling via Skype or Zoom. I understand that telemental health counseling may include the practice of grief support, consultation, and education using interactive audio, video, or data communications.
I understand the following with respect to Telemental health services:
I agree/do not agree to give permission for my child/teen to be photographed, videotaped, or interviewed and for his/her artwork to be photographer during the Center for Children program under supervision of staff. This material may be used for future publicity of the Center for Children program, including news media.
In consideration of the above-named child/teen being accepted by Hospice of the Piedmont to attend the Center for Children program:
I, for myself and on behalf of my child/teen, release and discharge Hospcie of the Piedmont, its staff, Board of Directors, Officers, Volunteers, from all claims, demands, actions and judgments, which I or my child/teen ever had or now has or may have against Hospice of the Piedmont for all personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by my child/teen's person or property during his or her participation in Center for Children camps or activities, including but not limited to, injury caused by negligence.
I agree to indemnify and hold harmless Hospice of the Piedmont, for any and all claims, demand, actions and judgments whatsoever of every name and nature, both in law and equity, which my child/teen ever had or now has or may have against Hospice of the Piedmont for all personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by my child/teen’s person or property during his or her attendance at Center for Children camps or activities, including but not limited to, injury caused by negligence.
I, the undersigned, have read this release and understand all of its items. I understand that this content is valid for one (1) year from date of agreement, or the date my child ends his/her involvement with the Center for Children programs described herein, whichever is later.
TERMS AND CONDITIONS: I give permission to staff of the Center for Children program to administer first aid to my child and authorize emergency transport to the nearest acute care facility.