LIABILITY WAIVER + CHILD INTAKE FORM
The Mindful Toolbox Location: 311 5th st., Crested Butte, CO Owner & Lead Teacher: Jessica Noll Contact: 480-266-9875 | TheMindfulToolbox@gmail.com www.TheMindfulToolbox.org
Parent/Guardian Full Name
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First Name
Last Name
Parent/Guardian Email Address
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example@example.com
Parent/Guardian Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
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First Name
Last Name
Child's Date of Birth
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Month
-
Day
Year
Date
Please tell us anything helpful about your child’s learning style, communication preferences, or physical/cognitive needs that may help us support them better(e.g., specific interests, motivators, special needs):
Child's Medical Information (allergies, injuries, physical limitations)
I give permission for The Mindful Toolbox to administer the following medication (including epi-pen)
Any other relevant medical or health considerations
Emergency Contact Name, Phone Number, and relationship to student (other than parent)
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Authorized Pickup Person(s) (Name and Relationship)
Not Authorized Pickup Person(s) (Name and Relationship)
Please indicate your media release preference:
Yes – Photos/videos may be taken and shared for promotional/advertising purposes.
Yes, but private – You may take photos/videos of my child and share them privately with me only.
No – I do not consent to photo or video documentation.
Please indicate your media release preference:
*
Yes – Photos/videos may be taken and shared for promotional/advertising purposes.
Yes, but private – You may take photos/videos of my child and share them privately with me only.
No – I do not consent to photo or video documentation.
By Signing below I hereby agree to the following:Liability Disclaimer: please read carefully. I individually and as parent and/or guardian of theminor child identified above hereby acknowledge the following notices and grant to The Mindful Toolbox the following release from liability: I acknowledge and fully understand that I, or my child,will be engaging in physical activities that may involve some risk of injury. I acknowledge andhave been advised that it is my responsibility to consult with my or my child’s physician withrespect to any past or present injury, illness, health problem or any other condition or medicationthat may affect my or my child’s participation. I assume the foregoing risks and accept fullpersonal responsibility for any personal injuries sustained by my child which might incur as aresult or participating in this program and discharge and hold harmless The Mindful Toolbox, itsowners, directors, members, employees and agents from any claim, cause of action or liabilityfor damages arising from any personal injury to my child or other persons or property caused bymyself or my child’s participation in any The Mindful Toolbox classes or programs.
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Date of Signature
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Month
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Day
Year
Date
Submit
Should be Empty: