Powerhouse Liability Release
Submitting this form is required before your child can participate in any programs offered by The Powerhouse.
Child's Information
Child's Name *
Your answer
Child's School *
Child's Date of Birth
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DD
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YYYY
Special Considerations
Please note any special needs, dietary restrictions or medications below.
Your answer
Parent's Information
Parent's Name *
Your answer
Address/State/City *
Your answer
Parent's Email Address *
Your answer
Parent's Phone Number *
Your answer
Alternate Emergency Contact *
Your answer
Photo / Video Consent *
The Powerhouse often photographs and/or videotapes our educational programs for educational and/or promotional purposes. We do NOT use personally identifying information - such as the child's name, address, etc. - in any promotional material.
Anything else you would like us to know?
Your answer
Agreement and Release of Liability *
BY SELECTING "I Agree" BELOW, you agree to the following: I hereby authorize any emergency service agency or physician and dentist associated with the emergency service agency to administer whatever medical care in their professional opinion is necessary for my minor child listed above. The Powerhouse, hospital, and any emergency service agency and their associated physicians, surgeons, and/or dentists have my authority to consult as necessary. I further agree to indemnify, hold harmless, release and forever discharge the staff, volunteers and Board of Directors of the Museum and all its officers, agents, and assistants from any claims which I or my heirs, or any persons acting on my behalf have or may have against The Powerhouse by reason of any accident, illness, injury or other consequences arising or resulting directly or indirectly from the participation of my minor child identified above in museum programs or events. This authorization is valid while my child is enrolled in programs of The Powerhouse, both on-site and off-site, or until revoked by me in writing. BY SELECTING THE OPTION BELOW, I AGREE TO THESE TERMS.
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