Bloom Consent for Use of Equipment
Please complete the following information before your initial visit.
Contact Information
Contact Information
Child's name
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First Name
Last Name
Child's date of birth
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Month
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Day
Year
Child's age
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Home address (no PO boxes)
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Street Address
Street Address Line 2
City
State
Postal / Zip Code
Parent / Caregiver name
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First Name
Last Name
Parent / Caregiver email
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Parent / Caregiver primary phone
*
Format: (000) 000-0000.
Parent / Caregiver other phone (optional)
Format: (000) 000-0000.
Parent / Caregiver #2 name (optional)
First Name
Last Name
Parent / Caregiver #2 email (optional)
example@example.com
Parent / Caregiver #2 primary phone (optional)
Format: (000) 000-0000.
Consent for Use of Equipment and Emergency Contact
Consent for Use of Equipment and Emergency Contact
Consent for Use of Equipment and Emergency Treatment
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I understand that my child will be involved in activities which may involve the use of equipment such as suspended equipment, swings, large therapy balls, tactile or touch media, gross motor, and fine motor activities and I give my child permission to engage in the various therapeutic activities described above.
In case of an emergency and I am not present, I give permission to the personnel of Bloom Pediatrics, Inc., into whose care my child has been given, the authority to consent to an x-ray examination, anesthetic, medical or surgical treatment and hospital care to be rendered under the supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical or Dental Practice Act.
In the event of a medical emergency and I am not present, I understand that the staff of Bloom will contact 911 or other appropriate medical personnel. If ambulance service must transport my child, I understand that it will be to the closest medical facility able to handle the situation. I understand that my child’s records are protected under state and federal confidentiality regulations and cannot be disclosed without prior written consent. I give my consent to allow the release of information and/or records/reports regarding my child for purposes of emergency medical treatment. I understand the staff of Bloom Pediatrics, Inc. will not be liable for any first aid treatment, medical or hospital care rendered, or drugs, medicine or surgical procedures performed pursuant to this consent.
Emergency contact (list someone other than primary parent/caregiver)
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First Name
Last Name
Emergency contact relationship to child
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Emergency contact primary phone
*
Format: (000) 000-0000.
Video and Picture / Social Media and Web Consent
Video and Picture / Social Media and Web Consent
Video and Picture Consent
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I GIVE CONSENT to Bloom to video and/or to take still photographs of my child for purposes to share my child’s accomplishments with me and to demonstrate their work done at Bloom. I understand the videos and/or pictures of my child will not be used for any other purpose. If I wish to revoke my permission in the future, I will submit my request in writing to Bloom.
I DO NOT GIVE CONSENT to Bloom to video and/or to take still photographs of my child.
Social Media and Web Consent
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I GIVE CONSENT to have my child’s photographs to be displayed on Bloom's website and social media in order to share my child’s accomplishments and demonstrate their work done at Bloom. I release Bloom, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. I hereby agree to hold Bloom, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor’s behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor’s likeness and photograph. If I wish to revoke my permission in the future, I will submit my request in writing to Bloom.
I DO NOT GIVE CONSENT to have my child’s photographs to be displayed on Bloom's website and social media.
Liability, Privacy, and Insurance Information
Liability, Privacy, and Insurance Information
COVID-19 Release of Liability
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I attest that I understand and agree to the following: I am fully aware that there are a number of risks associated with me and/or my child entering Bloom Pediatrics, Inc. property, participating in Bloom programs, and utilizing Bloom equipment and facilities during the COVID-19 pandemic. This waiver, release, and other representations and covenants set forth herein are given in consideration for Bloom Pediatrics, Inc. permitting me and/or my child to participate in Bloom programs during this emergency period. Therefore, without limitation, I understand that I and/or my child could contract COVID-19 disease which could result in a serious medical condition requiring medical treatment in a hospital or could possibly lead to death. On behalf of myself and/or my child and heirs, successors and assigns, I knowingly and freely, assume all such COVID-19 related risks, both known and unknown, relating to me and/or my child’s entry onto Bloom Pediatrics, Inc. property, participation in Bloom programs, and utilization of Bloom equipment and facilities as described above, and I hereby forever release, waive, relinquish, and discharge Bloom Pediatrics, Inc., along with its officers, agents, employees, or other representatives, and their successors and assigns (collectively, “Bloom Representatives”), from any and all COVID-19 related claims, demands, liabilities, rights, damages, expenses, and causes of action of whatever kind or nature, and other losses of any kind, whether known or unknown, foreseen or unforeseen, (collectively, “Damages”) as a result of me and/or my child entering onto Bloom Pediatrics, Inc. property, participating in Bloom programs, and utilizing equipment and facilities as described above, including but not limited to personal injuries, death, disease or property losses, or any other loss, and including but not limited to claims based on the alleged negligence of any Bloom Pediatrics, Inc. Representative or any other person related to COVID-19 sanitization. I further promise not to sue Bloom Pediatrics, Inc. or any Bloom Representative, and agree to indemnify and hold them harmless from any and all Damages resulting from me and/or my child’s contraction of COVID-19.
Family Policies and Procedures
Family Policies and Procedures
Non-Discrimination Policy
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I understand that Bloom strives to maintain an inclusive environment without discriminating on the basis of race, religion, sex, national origin, sexual orientation, age, or disability and that parents and caregivers are expected to participate in this endeavor and show mutual respect for members of our community.
Parent / Caregiver Signature and Date
Parent / Caregiver Signature and Date
By signing below, I attest that I understand and agree to the terms and conditions outlined above.
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Print name
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First Name
Last Name
Today's Date
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Month
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Day
Year
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