Medical Treatment Authorization Form
In consideration of my child’s participation in the Washington County Bicycle Transportation Coalition’s (BTC) Summer Bike Camp program, I hereby grant permission for the BTC staff, its camp instructors, volunteers, or other Bike Camp agents to select a physician to hospitalize and secure treatment for, and order other medical procedures for my child in the event of a serious illness or injury sustained during camp. I understand these actions will be taken only when the health of the child is in serious jeopardy and the parent or guardian is not present to direct care. I also understand that the “RELEASEES” defined below will not be liable for any costs associated with these actions or subsequent treatment.
I HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the BTC, its respective administrators, directors, agents, officers, members, volunteers, and employees, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS. And, I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim.
I am 18 years of age or older, have read and understand the terms of this agreement, understand that I am giving up substantial rights by signing this agreement, have signed it voluntarily and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law. I agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.
Minor’s Name (Printed)_____________________________________________________________
Parent/Guardian Name (Printed)________________________________________________________
Parent/Guardian Signature ________________________________________________________
I HAVE READ THIS RELEASE (Print Name)_______________________________________________
I HAVE READ THIS RELEASE (Signature) ________________________________________________