Game Night Registration

Parent/Guardian Information

Emergency Information

Informed Consent and Acknowledgment

I hereby give my approval for my child’s participation in any activities prepared by Child First Therapy, PLLC, during the selected event. In exchange for the acceptance of said child’s candidacy by Child First Therapy, PLLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless Child First Therapy, PLLC. and all its respective officers, agents, and representatives from any liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to the said child, I hereby waive all claims against  Child First Therapy, PLLC. including all staff and volunteers, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all clinic activities, including suspended equipment. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

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 from a serious illness, the need for major surgery, or a significant accidental injury, I understand that the attending physician will make every attempt to contact me in the most expeditious manner possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Child First Therapy, PLLC, and its affiliates, including Directors, Therapists, and other parents, to provide the needed emergency treatment before 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 the 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.