GPA PMA at The Enrichment Center of Long Island

Severe Allergy Disclosure, Medical Authorization, Assumption of Risk &
Liability Agreement
Toddler Program (Ages 2-5)

I, the undersigned parent/guardian, acknowledge that my child has been diagnosed with a severe food allergy, which may result in serious or life-threatening reactions, including but not limited to anaphylaxis.
I understand that this condition requires continuous monitoring, prevention, and emergency preparedness.

I acknowledge and agree that I am solely responsible for the medical management of my child's allergy, including but not limited to:

• Providing complete and accurate written medical information
• Supplying all required emergency medications (e.g., EpiPen)
• Ensuring medications are current, not expired, and clearly labeled
• Providing clear written instructions for use of all medications
• Replacing medications immediately upon expiration or use
• Informing GPA PMA immediately of any changes in condition or treatment

I understand that GPA PMA staff are not licensed medical professionals and are not responsible for diagnosing, treating, or managing medical conditions.

In the event of a suspected allergic reaction, I authorize GPA PMA staff to:

• Administer emergency medication provided by me (including but not limited to epinephrine auto-injectors)
• Contact emergency medical services (911)
• Seek emergency medical care as deemed necessary

I understand and agree that:

• Emergency response times cannot be guaranteed
• Outcomes cannot be guaranteed
• Actions will be taken in good faith based on the situation

I understand and acknowledge that:

• GPA PMA operates as a shared community environment
• Food is brought from outside sources by multiple families
• Young children may unintentionally share food or touch surfaces
• Cross-contact and accidental exposure may occur despite precautions

I acknowledge that GPA PMA is a nut-aware environment, not a nut-free guarantee.

I fully understand and acknowledge that:

• Exposure to allergens may result in severe injury or death
• It is not possible to eliminate all risk in a group setting
• Even with policies, supervision, and precautions, exposure may still occur

With full knowledge of the risks involved, I voluntarily choose to allow my child to participate in the GPA PMA Toddler Program.

I knowingly and voluntarily assume all risks, including the risk of accidental allergen exposure and resulting medical consequences.

To the fullest extent permitted by law, I hereby release, waive, and discharge:
GPA PMA, The Enrichment Center of Long Island, its directors, staff, volunteers, affiliates, and representatives from any and all claims, liabilities, damages, losses, or causes of action, whether known or unknown, arising out of or related to:

• Allergic reactions or anaphylaxis
• Exposure to peanuts, tree nuts, or any allergens
• Cross-contamination or accidental ingestion
• The administration or non-administration of emergency medication
• Any actions taken in good faith in response to an emergency

The undersigned parent/guardian agrees to indemnify, defend, and hold harmless GPA PMA at The Enrichment Center of Long Island, David Machson, and all directors, officers, staff members, instructors, volunteers, and affiliates from and against any and all claims, demands, causes of action, liabilities, damages, losses, or expenses (including reasonable attorneys' fees) arising out of or related to:

• (a) the child's participation in any program or activity at the Enrichment Center;
• (b) any allergic reaction, exposure, or other medical incident, including but not limited to those resulting from contact with or ingestion of food allergens; and
• (c) any act or omission by the parent/guardian or child, including failure to disclose complete and accurate medical information or failure to adhere to program policies, procedures, or food restrictions.

The parent/guardian acknowledges and understands that, despite reasonable precautions and safety measures, the Enrichment Center cannot guarantee an allergen-free environment and that the risk of accidental exposure is inherent in a group setting.
The parent/guardian further assumes full responsibility for all risks associated with the child's allergy and participation in the program and agrees that GPA PMA and its representatives shall not be held liable for any such incidents, except as required by applicable law.

I acknowledge that safety is a shared responsibility and agree to:

• Reinforce food safety practices with my child
• Provide safe and appropriate food when applicable
• Maintain open and timely communication with staff
• Act in good faith to support a safe environment for all children

I certify that:

• I have read this document in full
• I understand all terms and conditions
• I have had the opportunity to ask questions
• I voluntarily agree to all provisions