I hereby consent to the participation of the above persons in this activity. I am aware of the risk inherent in this activity and understand that this is a volunteer activity. On behalf of myself and the above listed person(s), I agree to forever release the sponsors, the Town of Ashland and its employees, agents, officers and officials from any and all claims, losses, right of action, injuries, and/or damages resulting from or relating to participation in this activity. I have determined the nature and extent of the planned activities, and feel the above persons are of sufficient age, ability and discretion to participate. I agree that this participation will be at the discretion of the Board of Health. On behalf of myself or as a parent or legal guardian of the above named participant(s), I hereby give my consent for any and all emergency medical care taken by adult certified, trained and/or licensed emergency care technician, doctor, dentist, nurse, first responder or other appropriate similarly licensed or certified personnel, as may be administered in the process of providing emergency care of whatever form necessary to preserve life, limb or well being. I authorize and request the Town of Ashland to give, disclose and release to any emergency care provider all individually identifiable health information as I have provided to the Town of Ashland. This authorization and request is a consent to the release of such information under current and future laws, rules and regulations, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and regulations promulgated pursuant thereunder. Unless noted on this form, the participants have no allergies or other problems which will interfere with normal participation. I further affirm that I have read this Consent and Release Form and that I understand the contents of this Form. I understand that my or my child’s participation in this program is voluntary and that we are free to choose not to participate in this program. By signing this Form, I affirm that I have decided to participate or have allowed my child to participate in the Town of Ashland’s “GreenUp Ashland” activities with full knowledge that the Town of Ashland will not be liable to anyone for personal injuries or property damage my child or I may suffer in the voluntary participation of the Town of Ashland’s “GreenUp Ashland” activities. *
