Permission for Treatment The health history provided on this form is correct to the best of my knowledge. By my signature below, I hereby grant permission and authorize the provision of emergency medical treatment for minors/students who become ill or injured while participating in an Artisan Alley program. Should an emergency arise while my child is under the supervision of the staff of Artisan Alley, I (we), do hereby authorize the staff to obtain and/or provide medical attention for my child. I (we), do hereby give consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine during the program period. I (we), do hereby give consent to the administration of an emergency prescription medication prescribed to the above named minor/student for which I (we) have provided written instruction. I (we) do hereby release and forever discharge Artisan Alley and its partner instructors and organizations, employees, volunteers, agents, officers, trustees, affiliates, and representatives from any and all liability of any kind for any claim, demand, action, cause of action, expense, judgment or cost, including without limitation, attorney’s fees, which arise out of or relate in any manner to the exercise of authority or judgment pursuant hereto, or to the securing, oversight, administration or supervision of medical or other care or treatment on behalf of my child at any time or any travel incident thereto.
Release of Information By my signature below, I authorize Artisan Alley to release medical information regarding the above named minor/student to any person or entity to whom Artisan Alley refers the minor/student for medical treatment.
Waiver Statement (Must be agreed to by signing at bottom of this page to participate) In consideration of permission to use the property, facilities and services of Artisan Alley, such use including, but not limited to, use of Artisan Alley’s facilities or equipment, participation in Artisan Alley programs or activities, and observation of any of the foregoing, I do hereby agree:
1. Release and Waiver of Liability ~ For myself and my heirs, assigns, personal representatives, executors and administrators, to waive, release, and forever discharge Artisan Alley and its respective directors, officers, employees, representatives and members (the “Releasees”) from liability for any loss or damage and from any rights, claims or demands therefore which I have or which may hereafter accrue to me arising out of injury to my person or my property incurred in connection with my use of the property, facilities or services of Artisan Alley, whether such damages are caused by the negligence of the Releasees.