I am the parent or legal guardian for the above-named participant and give my permission for him/her to attend activities sponsored by Reality Check. I hereby certify that the information provided is correct. In the case of a medical emergency, I understand that every effort will be made to contact the emergency contacts listed above. In the event those persons cannot be reached or time does not permit, I hereby give permission to a licensed physician or other licensed medical provider, to provide proper treatment, including but not limited to hospitalization, injection, anesthesia and/or surgery for the above-named participant.
On behalf of myself and my ward/minor, I/we hereby RELEASE, WAIVE and FOREVER DISCHARGE St. Peter’s Health Partners and its officers, directors, employees, parents and subsidiaries, agents, from any and all claims, liabilities, causes of actions, damages, demands, judgments, executions, liens and costs whatsoever, in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (i) claims made against medical providers of emergency services (who are not employed by St. Peter’s Health Partners) under this authorization, or (ii) against St. Peter’s Health Partners for obtaining medical emergency services for said participant pursuant to this authorization.