Pathways to Success Counseling LLC
Child Safety and Liability Waiver
· Parents/guardians acknowledge that participation in group therapy and related activities involves inherent risks.
· Pathways to Success Counseling LLC and its staff are not liable for injuries, damages, or losses sustained during participation, except in cases of gross negligence or misconduct.
· All children and parents will sign a liability waiver before participating in any programs.
Program Name: Pathways to Success Counseling (all programs and community center use)
Child’s Name: __________________________________________
Parent/Guardian Name: __________________________________________
Date: __________________
Purpose of this Waiver:
The safety of all children participating in our programs is our top priority. To maintain a secure environment, all parents/guardians must review and sign this waiver acknowledging the expectations, responsibilities, and release of liability related to their child’s participation in activities at Pathways to Success Counseling LLC ("Pathways").
Safety Rules & Expectations:
By signing below, I acknowledge that I have reviewed these safety expectations with my child, and we both agree to the following rules:
Property Boundaries:
Children must remain on Pathways property at all times unless accompanied by a parent or legal guardian. Staff are not responsible for a child leaving the property.
Children are strictly prohibited from entering the street, parking lot, or leaving the premises without their legal guardian.
Bathroom and Kitchen Safety:
Children will use the restroom facilities responsibly and respectfully, following any posted guidelines and instructions provided by staff.
The community breakroom may only be used under staff supervision, and children must not handle sharp objects, hot surfaces, or other potentially hazardous equipment.
Equipment and Facility Use:
Children will use all toys, games, furniture, and facility equipment appropriately and safely.
Misuse of equipment, rough play, climbing on high surfaces, or other unsafe behavior will not be tolerated.
Tolerance:
o Pathways to Success Counseling and Pathways Community Center do not tolerate bullying, inappropriate language or non-inclusive language. Any threat or jokes of threats towards another person are never to be tolerated. We are inclusive to all and support diversity, equity and inclusion.
Supervision:
While Pathways staff will provide appropriate supervision during programming, it is understood that staff cannot prevent all injuries or incidents that may result from unforeseen behavior or unsafe actions.
Acknowledgement of Risk:
I understand that participation in group therapy, skill-building activities, and play involves inherent risks, including but not limited to:
o Trips, falls, and minor injuries.
o Accidents related to improper use of facilities or equipment.
o Risks of a child leaving the property boundaries without permission.
o Burns or Cuts from mishandling kitchen equipment
Release of Liability:
By signing this waiver, I agree that:
I, on behalf of myself, my child, and our representatives, release, discharge, and hold harmless Pathways to Success Counseling LLC, its owners, employees, volunteers, and agents from any and all liability, claims, demands, or causes of action arising from my child’s participation in programs, including injuries, accidents, or incidents occurring if:
My child leaves the property without authorization.
My child enters the street or parking lot unsupervised.
My child uses equipment, furniture, or spaces in an unsafe or unintended manner.
My child fails to follow the established safety rules and expectations.
Medical Treatment Authorization: ___________
In the event of an injury or medical emergency, I authorize Pathways to Success Counseling LLC staff to administer basic first aid and contact emergency services if necessary. I understand that any medical costs incurred are my sole responsibility.
Agreement:
I have read and understood this waiver in its entirety. I understand that failure to follow safety rules may result in my child being dismissed from the program without refund. I agree to discuss these expectations with my child and ensure their cooperation.
Parent/Guardian Name (Printed): __________________________________________
Parent/Guardian Signature: __________________________________________
Date: __________________
Child’s Name (Printed): __________________________________________
Child’s Signature (if appropriate): __________________________________________
Date: __________________