Youth Wavier and Health Form

Youth Wavier and Health Form

Paper Waiver and Health forms available upon request.
• I am the legal parent or guardian of the Student.

• The Student will be participating in sewing instruction led by Hartford Stitch, LLC.

• I am aware that the activities often involve using equipment that can cause injury, including needles, sharp blades and hot irons.

• I understand that it is my responsibility to decide if the Student is qualified to participate in the activities, and I assume all risks and accept personal responsibility for any potential damages arising from their participation.

• I will instruct the Student to carefully listen to and follow all safety and other instructions given by Hartford Stitch instructors and to inform instructors if they are in any way unsure of how to use specific equipment.

• I understand Hartford Stitch may take group and individual photos (or videos) of Students participating in the activities for use (without identifying information such as the Student’s name) on the website, in brochures, and other marketing of Hartford Stitch, and I allow Hartford Stitch to do this without any compensation. Hartford Stitch makes every effort not to include photos with identifying information, including faces and names, on social media and websites. Photos of faces may be used internally including our yearly poster and pattern photos.

• I, on behalf of the Student and on my own behalf, release, waive, and agree to hold harmless Hartford Stitch and it’s staff, (the “Indemnified Parties”) from any claims or issues that arise from the Student participating in the activities and to indemnify the Indemnified Parties for any liability and costs (including attorney’s fees) related to any claim arising from Student participating in the activities.
Student Name

First NameLast Name
Student Birthday*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Parent Email*
example@example.com
Best Contact Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Medical Information
Preferred hospital
Please list any allergies or special concerns
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Parent/Guardian Signature

Clear
Should be Empty:

Youth Wavier and Health Form

EMERGENCY CONTACT INFORMATION

Medical Information