Date : July 17th 1:00-3:00 PM Location : Mitchells Homemade Ice Cream 1867 W 25th St, Cleveland, OH 44113

Adoption Network Cleveland.

Participants are responsible for securing their own rides to and from Mitchells Homemade Ice Cream at 1867 W 25th St, Cleveland, OH 44113 (216) 861-2799.

I/We understand that Adoption Network Cleveland, does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to and authorize the above-named activity supervisor(s) to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s).

I release and waive, and further agree to indemnify, hold harmless or reimburse Adoption Network Cleveland, the individual members, agents, employees and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses, damages or injuries arising out of, during, or in connection with the child's participation in the activities (including all forms of transportation) or the rendering of emergency medical procedures or treatment, if any.

If, in the event of a medical or other emergency, I am unable to be reached by telephone at my home or work telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.