I, the Responsible Party, give permission for the client listed above, to participate in a developmental screening by Moving Mountains Foundation. I agree to Moving Mountains Foundation sharing the results of this screening with affiliated partners and community resources as applicable.
Waiver of Liability: In return for being allowed to participate in Moving Mountains Foundation’s screening and education program, the undersigned responsible party releases and agrees not to sue Moving Mountains Foundation or its officers, preferred providers, directors, employees, sub-contractors, sponsors, agents and affiliates from all present and future claims or assigns for property damage, personal injury, or wrongful death arising as a result of my participation in the screening and education program, even if caused by ordinary negligence. I also acknowledge that Moving Mountains Foundation has not arranged and does not carry any insurance of any kind for the officers, preferred providers, directors, employees, sub-contractors, sponsors, agents and affiliates. I also understand that this document is a contract that grants certain rights to and eliminates the liability of the Moving Mountains Foundation.
Disclaimer: This screening does NOT replace a formal evaluation from a licensed speech-language pathologist, or physical or occupational therapist, or a mental health counselor, diagnose a delay or disorder, or qualify your child for therapeutic services.