• Participant Enrollment

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  • Participant Information

  • Parent/Guardian Information

  • Emergency Contact Information

  • FAMILY DEMOGRAPHICS

  • In consideration of my child(ren)'s participation in the programs sponsored by City of Buffalo and/or the Police Athletic League of Buffalo (PAL), the undersigned hereby agrees not to sue, and hereby release the City of Buffalo, City employees, PAL, its Board of Directors, members, agents, employees and volunteers from any and all liability for any damage or injury to me/my child(ren) or to the property, sustained by me/my child(ren) caused or resulting from any cause whatsoever. I acknowledge that I assume all risk of injury from such participation in activities at any PAL facility or other program site and acknowledge that photographs of my child(ren) participating in this program may be used for promotion of PAL and/or City of Buffalo activities.

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  • Authorization for Medical Treatment

  • This release and consent gives Full Circle Family Services Inc. permission to take my child to the nearest available medical facility and have any necessary emergency treatment administered. I understand that every effort will be made to contact me. However, in case of emergency, if I cannot be reached, I hereby give Full Circle Family Services Inc. permission to act on my behalf in seeking medical treatment by qualified personnel for my child in the event that such treatment is deemed necessary or advisable for my child’s health, safety and welfare. I release Full Circle Family Services Inc. and all medical providers from liability in acting on my behalf in this regard in rendering such medical treatment.

    This authorization for Emergency Medical Treatment must be completed before participant can participate in any activities. Treatment for injury will be based on information provided herein.

  • Release of Liability

  • Full Circle Family Services Disclaimer (click to read)

  • I hereby grant permission for my daughter/son to participate in the Full Circle Family Services Inc. Mentor Program. I understand and acknowledge that this program is voluntary, and there is no requirement that my daughter/son participates in this program. If any other contacts are planned, the mentor will obtain advanced, written parental permission. Finally, I understand that I may withdraw my permission at any time by written notification and that my daughter/son will thereafter be withdrawn from the mentor program.

  • I understand that participating in Full Circle Family Services Inc activities is a privilege. In consideration of this privilege, I release Full Circle Family Services Inc, including its directors, volunteers, employees and agents from any physical injury I understand that my child and/or I may participate in any number of activities, some of which include, but are not limited to, recreational activities and games. I understand that there are certain risks associated with any activity; I will assume responsibility for these risks, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representative or assigns. If I am under 18, my parent or guardian, by signing below, also consents to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representatives and assigns. My parent or guardian also promises, by signing below to defend, indemnify and hold Full Circle Family Services Inc harmless from any claim asserted by me against Full Circle Family Services Inc, including its directors, volunteers, employees and agents, if I should repudiate this release after obtaining adulthood. Consent I hereby grant permission to Full Circle Family Services Inc the right to use, reproduce, and/or distribute photographs, films, videotapes, and sound recordings of my child, without compensation or approval rights, for use in materials created for purposes of promoting the activities of Full Circle Family Services Inc.

  • ACKNOWLEDGEMENT and SIGNATURE

  • I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT that is binding upon myself and my heirs, executors, administrators, successors and assigns. I HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT and I ACKNOWLEDGE THAT by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that my child or I may have.

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