Emergency Contact Information-Alternate Pick-Release
Emergency Contact #1
Emergency Contact #2
Your child will not be released to anyone that is not listed above. Please contact us in advance for occasions where an individual not listed will be picking up your child.
Medical Release Information
The purpose of the above listed information is to ensure that medical personnel have details of any medical condition which may intefere with or alter treatment.
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured.
THERAPEUTIC LEARNING CENTER, LLC
Permission Slip, Waiver of Liability, Indemnification, Medical Agreement
and Grant of Rights
I, the parent/legal guardian of this participant, hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Thanksgiving and Winter Programs (“Program”). I understand that the Program is completely voluntary and that no academic credit will be given for participation. My signature below is an acknowledgment of voluntary consent to allow my child to participate in this Program.
Waiver of Liability
My signature below indicates my understanding of the details of the Program. On behalf of my child, I voluntarily agree to accept any and all risks associated with their participation in the Program. On behalf of my child, I agree to forever indemnify, hold harmless, waive, and release TLC, its respective officers, members, employees, insurers, and representatives (“TLC Group”) thereof, from liability for any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have on my behalf or on behalf of my child, known or unknown, directly or indirectly, for any losses, damages, or injuries, including death, arising from, but not limited to, negligence, omissions, or fault, by or on behalf of TLC.
I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the Program.
If the participant has any special medical problems, allergies, dietary needs, handicaps, special prescriptions, etc., please list (and use additional sheets if necessary) I have explained them in the registration form above.
In case of an emergency, all attempts to reach me should be made to the telephone number(s) stated above on the registration form.
If any emergency medical procedures or treatments are required during the Program, I hereby consent to the staff of TLC’s Program, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter. My signature below also indicates that my child is in adequate physical condition to participate in the Program.
GRANT OF RIGHTS
I, Parent/Legal Guardian, grant TLC the right and license to use my child’s liken, photographs and other attributes (collectively, “Approved Attributes”) to promote and advertise TLC’s services in the media including TV, radio, print advertising, point-of-sale materials, promotional materials, grassroots marketing efforts, public relations efforts and the Internet (to include but not be limited to web banners, blogs and social networking sites).
By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, WAIVER OF LIABILITY, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.
The Undersigned expressly agrees that the foregoing Release, Waiver and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.
READ BEFORE SIGNING
Check the Fall program you wish to enroll your child/children. Please contact the office to provide a payment method if you would like to pay in person or using another method.
Fall session payment is due by November 20th and Winter session payment is due on December 18. The office will send you an invoice for payment. Call 504-565-7300 for more details.