Cottage Location -

Cottage Location - Policies + Release

WAIVER OF LIABILITY, INDEMNIFICATION, AND MEDICAL RELEASE
Acknowledgment and Assumption of Risk
I am aware of the dangers and the risks to my person and property involved in participating in speech therapy, occupational therapy, physical therapy or any of the additional programming offered by Communication Cottage Therapy, LLC*
I understand that this activity involves certain risks for injury *
I also understand that there are potential risks of which I may not presently be aware. Because of the dangers of participating in this activity, I recognize the importance and agree to fully comply with the applicable laws, policies, rules, and regulations, and any supervisor’s instructions regarding participation in this activity. I understand that Communication Cottage Therapy, LLC does not insure participants in the above-described activity, that any coverage would be through personal insurance, and Communication Cottage Therapy, LLC has no responsibility or liability for injury resulting from this activity. I voluntarily elect to participate in this activity with knowledge of the danger involved, and I hereby agree to accept and assume any and all risks of property damage, personal injury, or death.*
Waiver of Liability and Indemnification:
In consideration for being allowed to voluntarily participate in the above-referenced activities, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever:

a) waive, release, and discharge Communication Cottage Therapy, LLC and its agencies, officers, and employees from any and all negligence and liability for my death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event; and

b) agree to defend, indemnify, and hold harmless Communication Cottage Therapy LLC, its agencies, officers and employees, from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from participant’s actions during this activity or event.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.
I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement.

I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.
Guardian's name

First NameLast Name
Child's Name

First NameLast Name
Please be sure to read prior to signing this agreement

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Communication Cottage Therapy, LLC - Cottage Policies
I understand that I am to remain on the premise of 5000 Highway 17 Bypass South Myrtle Beach SC 29588 for the entire duration of my child's session. I am encouraged to be in the therapy room. Alternative locations to wait include: lobby, porch, or vehicle. *
I understand that it is my responsibility to keep the office admin staff up to date on my child's allergies. *
Current Comprehensive List of Allergies Known to Date
I understand that attendance is important to my child's quality of care. I will abide by the attendance policy listed in the consent forms.*
I understand that if I arrive early for a session, my provider may not be able to see my child until my scheduled time. *
I understand that if I arrive late to a session this impacts the amount of minutes that my child can be seen due to providers needing to adhere to their schedules. *
I understand that I can complete a survey to provide my suggestions to Communication Cottage Therapy, LLC regarding services. This can be found on the website under "forms" .*
I understand that if my child is working on potty training that they are to be wearing a pull up or diaper to ensure that the rooms stay as sanitary as possible.*
I understand that Communication Cottage Therapy, LLC has a security system in place that includes cameras.*
I have toured the facility and have seen the room features, possibilities for injury, and consent to having my child seen at Communication Cottage Therapy, LLC for therapy services (occupational, physical therapy, speech therapy)*
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Cottage Location - Policies + Release

Acknowledgment and Assumption of Risk

Waiver of Liability and Indemnification:

Communication Cottage Therapy, LLC - Cottage Policies