Occupational Therapy Outdoor Explorations Group

Parent/Guardian Information

Emergency Information

Informed Consent and Acknowledgement

I hereby agree to indemnify and hold Kidnetics Pediatric Therapy and all its officers, directors, employees, representatives and volunteers harmless from and against any and all liabilities for any injury which may be suffered by me or by my child(ren) arising out of or in any way connected with participation in the Kidnetics Pediatric Therapy program.

In the case of a medical or surgical emergency, I hereby give permission, to any medical personnel selected by the staff, to secure proper treatment. I give my full permission for my child(ren) to participate in activities, including but not limited to, hiking, running, climbing trees and playing in water. I acknowledge that group activities may contain an inherent risk of injury.

Any controversy or claim arising out of or related to my child(ren)’s participation in this group will be attempted to be settled by a professional mediation service, then by binding arbitration pursuant to the applicable rules of the American Arbitration Association.

I acknowledge that I understand that the group is non-refundable unless Kidnetics Pediatric Therapy has been advised to cancel the group by public health officials. If a day needs to be canceled, there may be a makeup day added at the end of the session or the pro-rated amount for the missed date may be applied to future services.

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Kidnetics Pediatric Therapy and its affiliates including therapists and employees to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.