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Student Information
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Parent's Name *
Child's name *
Address *
City *
State *
Zip *
Email *
Phone *
Child's Birth Date *
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Session or class; for example "Realm", "Scout Troop 41", "Tool Training" "Robin's Birthday Party" *
What is the date of the event? *
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Who's birthday are you attending? For other programming write N/A *
AnchorRelease of Liability, Assumption of Risk, Indemnification, andMedical Release AgreementNOTICE:This document affects your legal rights; please read carefully before signing. Handwritten changes to this document are not permitted.I, the undersigned, being at least 18 years of age, hereby represent that I am the Parent or Guardiandesire to participate in activities operated by reDiscover Center.On behalf of myself and each above-referenced child, and my/our representatives, heirs, next of kin, successors and assigns (collectively, “Participant”), I agree as follows:ASSUMPTION OF RISK: Each Participant agrees and acknowledges that there are risks in participating in (1) on-site activities through and/or using facilities or equipment of reDiscover Center; or (2) online or at-home activities provided by reDiscover Center, utilizingtools (“Tool Kit”) provided by reDiscover Center (collectively, the “Activities”), including risk of physical injury, contraction of virus, disability, death and/or damage to, or loss of, personal property (collectively, the “Risks”). Each Participant knowingly and freely assumes all of the Risks, including, without limitation, those arising from the negligence of reDiscover Center or its employees, agents, officers or directors (collectively, “reDiscover Center Affiliates”).TOOL KIT: Tool Kit may include, without limitation, tools such as saws, drills, and glue guns.Each Participant agrees and acknowledges that if Tool Kit is delivered to Participant in connection with the Activities, such Participant, upon receipt, knowingly and freely assumes all of the Risks arising from using Tool Kit irrespective of whether such Tool Kit was (i) purchased or rented from reDiscover Center; (ii) used within or outside the facilities or premises of reDiscover Center; or (iii) used as part of the Activities or non-Activities. reDiscover Center has no liability whatsoever for Risks assumed by Participant in using such Tool Kit.COVID-19: Each Participant acknowledges that COVID-19 infections (“COVID-19”) have been confirmed throughout the United States. In accordance with the guidance and protocols issued by the World Health Organization, the Centers for Disease Control and Prevention, and California Department of Public Health, each Participant agrees, represents and warrants that neither the undersigned nor Participant shall visit or utilize the facilities and programs of reDiscover Center (i) after exposure to any person who has a suspected or confirmed case of COVID-19, (ii) within 14 days after returning from highly impacted areas subject to a CDC Level 3 Travel Health Notice or (iii) if Participant is experiencing any COVID-19 symptoms such as, without limitation, fever, cough, sore throat or shortness of breath or has otherwise a suspected, diagnosed or confirmed case of COVID-19. For full symptoms related to COVID-19, visit https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.RELEASE OF LIABILITY: Each Participant hereby releases and forever discharges reDiscover Center Affiliates from any and all claims, actions, damages, liabilities, costs or expenses and attorneys’ fees (collectively, “Losses”) that are related to, arise out of, or are in any way connected to the Activities, COVID-19, Tool Kit and the Risks assumed. This release does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that California law does not permit to be excluded by agreement. Each Participant also agrees not to sue or make a claim against reDiscover Center Affiliates in connection with the Activities, COVID-19, Tool Kit and the Risks assumed.INDEMNIFICATION: The undersigned agrees jointly and severally to indemnify, hold harmless, and defend reDiscover Center Affiliates from and against any and all Losses (including for ordinary negligence) which may arise from a breach or action by any Participant of this agreement in connection with the Activities, COVID-19, Tool Kit and the Risks assumed, or from any lack of capacity on Participant’s part to execute this agreement on behalf of Participant. The undersigned further agrees, jointly and severally, to be financially responsible for any damage to property Participant may cause during an Activity.EMERGENCY CONSENT: In case of emergency, the undersigned hereby give permission to reDiscover Center to order treatment for Participant. This includes any necessary medical treatment and x-rays.The undersigned understands that this authorization is given prior to any need for medical care, but given to avoid unnecessary delay in emergency treatment which the attendant and/or medical professional may deem advisable in the exercise of best judgment. The undersigned further agrees that reDiscover Center Affiliates shall not be liable under any circumstances to anyone for exercising and/or ordering emergency medical treatment for Participant.PHOTO RELEASE: We take photographs as a method of recording activities and sharing with the public on our website and in our printed marketing materials. The undersigned gives his or her permission to reDiscover Center to use photographs of Participant, obtained during this program for any internal, informational, or publicity purposes deemed appropriate by reDiscover Center. On behalf of Participant, the undersigned releases reDiscover Center Affiliates from any and all liabilities arising from the use of the name or photograph of Participant in items including, but not limited to, news releases, brochures, and the organization’s website and the undersigned waives the right to inspect/approve the finished items or to receive remuneration for such uses.GENERAL: This agreement will be governed and construed in accordance with the laws of the State of California. Each Participant agrees that this agreement shall be an enforceable waiver, release and indemnity that will be broadly interpreted to the maximum extent permitted by California law. Each Participant agrees that if any portion or provision of this agreement is found to be invalid or unenforceable, then the remainder will remain in full force and effect.ACKNOWLEGEMENT OF UNDERSTANDING: To the extent any Participant is a minor, I represent and warrant that I am the Parent or legal Guardian of each such Participant and that I am acting in such capacity in executing this document. I HAVE CAREFULLY READ the foregoing Release of Liability, Assumption of Risk, Indemnification, and Medical Release Agreement. I understand that this agreement relates to surrendering valuable legal rights of Participant(s) - including the right to sue. I understand, and I agree to be legally bound by all the terms and conditions in this agreement to the maximum extent permitted by law. I agree, and shall procure each minor Participant to agree, to follow all laws, rules and guidelines regulating the conduct of the program. I acknowledge and agree that no oral representations, statements, or other inducements to sign this agreement were made apart from what is contained in this agreement. I further acknowledge that this is the complete and entire agreement and that I am signing this agreement freely, fully and voluntarily. *
Parent/Guardian Electronic Signature *
Child's physician *
Child's physician's phone number *
If needed staff may administer (check all that are ok) *
Required
If needed staff may clean and apply antiseptic cream to a minor cut, insect bite or sting. *
Other medical information we need to know about your child (allergies, etc.) *
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