I, Parent/Guardian First Name*   Parent/Guardian Last Name*  give consent for my childChild First Name*   Child Last Name*   to engage voluntarily in any exercise activities during the Youth 4 Health classes of the Missouri Bootheel Regional Consortium, Inc. (MBRC, Inc.) Bootheel Health Alliance program. I understand that the activities are designed to place a gradually increasing workload on the body in order to improve overall fitness. I understand that I am responsible for monitoring my child’s condition throughout his/her workouts and should any unusual symptoms occur, I would cease my child’s participation and seek care or council for him/her.
In signing this consent form, I affirm I have read, accept and understand this form in its entirety and that I understand the nature of exercise. I know that there may be risks associated with exercise and willingly accept those possibilities. I know that it is my responsibility to ensure my child’s safety. I take full responsibility for my child’s health and safety in participating in any exercise activities and to the extent I deem advisable, will consult a physician for my child before letting him/her participate in any of the activities.
YOUTH AGREEMENT AND WAIVER/ RELEASE OF LIABILITY
In consideration for being allowed to participate in this program, which I give permission for my child to do freely and voluntarily for his/her own personal benefit, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns to:
1.     Waive, release and discharge from any and all liability Missouri Bootheel Regional Consortium, Inc. (MBRC, Inc.) and its Bootheel Health Alliance program, their elected and appointed officials, employees and volunteers, from any claims arising from my participation in the Bootheel Health Alliance program.
2.     Indemnify and hold harmless Missouri Bootheel Regional Consortium, Inc. (MBRC, Inc.) and its Bootheel Health Alliance program, their elected and appointed officials, employees, and volunteers, from any and all liabilities or claims made by other individuals or entities as a result of or relating to my participation in this activity
Therefore, intending to be bound and as a condition of being allowing my child to participate in the Bootheel Health Alliance program, I have freely signed this waiver on the date indicated.

I, Parent/Guardian First Name* Parent/Guardian First Name* ,give unrestricted permission for the images of myself and my child, Child First Name*Child Last Name* , to be photographed for publication and displays by Missouri Bootheel Regional Consortium, Inc. (MBRC, Inc.), and its Bootheel Health Alliance, Missouri Bootheel, Missouri Bootheel Healthy Start (MBHS), Fatherhood First, and future programs.

I Parent/Guardian First Name* Parent/Guardian Last Name* , give unrestricted permission for the images of myself and my child to be used in print, exhibit displays, publications, video, and digital media. I agree that these images may be used by MBRC, Inc. and its above mentioned programs for a variety of purposes and that these images may be used without further notifying me. These photographs and negatives will become the property of MBRC, Inc.

The purpose of MBRC, Inc. and its above listed programs is to strengthen, promote, and empower families and communities through quality focused programs to improve the health and well-being of infants, mothers, fathers, and families in the counties of Dunklin, Mississippi, New Madrid, Pemiscot, and Scott.

The Missouri Bootheel Regional Consortium, Inc. and its programs sponsor and partner with many conferences/workshops/seminars/trainings and often display tabletop exhibits with colorful and interesting photographs of children and adults. No names of children or adults will be used in the display.