2018 - 2019 Informed Consent and Hold Harmless/Release Agreement
Informed Consent and Hold Harmless/Release Agreement

I understand that participation in QCRA and BOW Community Robotics activities involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself and/or my child to participate in these activities.

I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release QCRA and BOW Community Robotics, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.

I approve the sharing of the information on this form with QCRA Robotics volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of activities.

In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose to the adult in charge Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information 45 C.F.R. §§160.103 164.501, etc. seq., as amended from time to time, including examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow –up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

Restrictions *
Special Restrictions
Your answer
Photography, Film Video Consent
I hereby assign and grant to QCRA and BOW Community Robotics the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made by me or my child at all QCRA and BOW Community Robotics activities, and I hereby release QCRA Robotics, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication.

I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitations at the discretion of QCRA and BOW Community Robotics, and I specifically waive any right to any compensation I may have for any of the foregoing.

*
Participant's Name *
Your answer
Participant's Signature
Entering your name below represents your signature and consent
Enter participant's first and last name
Your answer
Date
MM
/
DD
/
YYYY
Parent/Guardian Signature
Entering your name below represents your signature and consent
Enter parent/guardian's first and last name
Your answer
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service