Fill and Sign the Camp Overflow Leader Packet Trinity Pines Conference Center Form

Consent to Head Lice Removal for a Minor, Release of Practitioner from Liability, and Indemnity Agreement Consent and release executed on the ___________________ (date)by __________________________ (Name of Parent or Guardian), Individually and on behalf of _____________________ (Name of Minor) both of __________________________________ ____________________________________________ (street address, city, state, zip code), hereinafter jointly called Releasor, to and in favor of and ___________________________ (Name of Practitioner) , a Registered Nurse of the State of ________________, of __________ ____________________________________________________________________________ (street address, city, county, state, zip code) , referred to herein as Practitioner. Whereas, it is the opinion of Practitioner and the undersigned Parent and Guardian of ______________________ (Name of Minor), hereinafter referred to as the Minor, that the Minor would benefit from the following described treatment for head lice (describe Treatment) ____________________________________________________________________________ _______________________________________________________________________; and Whereas, said treatment for head lice is hereinafter called the Treatment; and Whereas, Releasor has been advised by Practitionerof the dangers associated with the Treatment, and possible complications from, such Treatment, said dangers and complications being _______________________________________________________________________ ___________________________________________________________ (describe fully); and Whereas, Practitioner is qualified and willing to perform the Treatment; and Whereas, before such Treatment will be performed, Releasor must consent to the Treatment and must release Practitioner and the employees of Practitioner who propose to perform the Treatment, from all liability that may result from the Treatment. Now, therefore, for and in consideration of the Treatment to be performed and any further Treatment that may, in the opinion of the Practitioner, be necessary, Releasor, fully realizing that such Treatment may be unsuccessful, that it may have certain complications, including, but not limited to, (describe in detail) _____________________________________ ____________________________________________________________________________ ____________________________________________________________________________, the undersigned requests that such Treatment be performed on the Minor, and further states and agrees to the following: 1. The undersigned Releasor hereby certifies and represents to Practitioner that: A. Minor has seen a physician for the condition of head lice; and B. Said physician has recommended that the Treatment be performed on Minor. 2. The undersigned Releasor consents to the Treatment. 3. Releasor releases and forever discharges Practitioner and the employees of Practitioner from all claims, damages and causes of action that may arise from the Treatment described in this Consent and Release , and from other medical care arising from the same. 4.Releasor further agrees to indemnify and hold harmless Practitioner and the employees of Practitioner for any claim, demand, losses, or damages arising out of any personal injury or property damage to my child ________________ (Name of Minor) as a result of the Treatment. 5. Releasor agrees that no representations have been made regarding the success of this Treatment, except as set forth in this Consent and Release. 6. This Release shall be binding on Releasor, his/her spouse, and on the heirs, legal representatives and assigns of Releasor. 7. Releasor has read all the terms of this instrument and understands that he/she is signing a complete release and bar to any claim resulting from the Treatment described in this Consent and Release. Witness my signature as of the day and date set forth above. _____________________________ (Printed Name of Parent) _____________________________ (Signature of Parent) Individually and for and on behalf of _____________________(Name of Minor) Acknowledgment (form may differ by state) State of _______________ County of _______________ I, ___________________ (name of officer), a Notary Public, do hereby certify that __________________________ (Name of Parent)and, personally appeared before me this day individually, and as the parent and guardian of __________________ (Name of Minor), and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this _____________________ (date of execution) . ______________________________ (Name of officer) ______________________________ (Title of officer) My commission expires on ___________________ (date). (Seal)