Dear Responsible Party,
If the developmental screening does not indicate a need for a formal evaluation, then no further action will be recommended. If the screening indicates areas where your child could benefit from a formal evaluation, you will be provided with community resources for speech therapy, physical therapy, occupational therapy, and/or counseling services.
I, the Responsible Party, give permission for the child listed above, to participate in a developmental screening organized by Moving Mountains Foundation and administered by a third-party provider such as the University of Montana, Kidzoola, or Moving Mountains Therapy Center staff. I agree it is my sole responsibility to share the results of this screening with site staff and administrators, 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 and any third-party provider administering the screening, including their 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 and any third-party provider involved in administering the screening.
Relationship Acknowledgement: By granting permission for the client listed above to participate in Moving Mountains Foundation’s screening and education program, the undersigned responsible party acknowledges that it has had the opportunity review the document entitled “Informational Letter” which is provided to the center director or can be also requested from MMF. The undersigned party understands that the University of Montana and Moving Mountains Foundation are independent entities, and none of the acts of either party shall be construed to be acts by, or on the behalf of, the other party. The undersigned party further understands that neither the University of Montana nor Moving Mountains Foundation assumes responsibility for any act or omission on the part of the other, including each entity’s respective employees, agents, affiliates, or officers.
Disclaimer: This screening does NOT replace a formal evaluation from a licensed speech-language pathologist, physical therapist, occupational therapist, audiologist or a mental health counselor, diagnose a delay or disorder, or qualify your child for therapeutic services.