Minor Liability Release

MINOR LIABILITY RELEASE AND AGREEMENT

RECITALS

WHEREAS, Organization Name: provides programs, activities, instruction and supervision for minors; and

WHEREAS, Parent/Guardian Name: is the lawful parent or legal guardian of Minor Name: , born on ;

WHEREAS, Parent/Guardian desires that Minor participate in the activity described below and is willing to accept the terms and conditions set forth in this Release and Agreement.

SCOPE OF ACTIVITY

SCHEDULE & PAYMENT TERMS

Late Fee (if payment not received when due):   Collection Costs: party in default shall be responsible for reasonable collection costs and attorneys' fees.

TERM AND TERMINATION

Term Commencement Date:    Term End Date:

Either party may terminate this Agreement for material breach by providing written notice delivered to the other party at least days prior to the effective termination date. Termination shall not relieve Parent/Guardian of obligations accrued prior to termination.

ASSUMPTION OF RISK; RELEASE; INDEMNIFICATION

In consideration of the opportunity for Minor to participate in the activity, Parent/Guardian hereby acknowledges and agrees that participation involves inherent risks, hazards and dangers which may result in injury, death, property loss or damage. Parent/Guardian voluntarily assumes all risk on behalf of Minor.

Parent/Guardian, on behalf of Minor and Parent/Guardian's heirs, assigns and personal representatives, hereby fully and forever releases, waives, discharges and covenants not to sue Organization Name: , its directors, officers, employees, volunteers, agents and affiliates (collectively "Releasees") from any and all liability, claims, demands, losses or causes of action that may arise out of or relate to Minor's participation, whether caused by the negligence of Releasees or otherwise, to the fullest extent permitted by law.

Parent/Guardian agrees to indemnify, defend and hold harmless Releasees from and against any liability, loss, damage or expense, including reasonable attorneys' fees and costs, arising from or related to Minor's participation or any breach of this Agreement by Parent/Guardian.

I acknowledge that I have read, understand, and voluntarily agree to the Assumption of Risk, Release, and Indemnification provisions set forth above.

MEDICAL AUTHORIZATION

Parent/Guardian hereby authorizes Releasees to obtain emergency medical treatment for Minor when, in the opinion of a representative of Releasees, such treatment is reasonably necessary. Parent/Guardian agrees to be financially responsible for all costs associated with such treatment and to indemnify Releasees for any costs incurred.

I consent to non-emergency medical care and first aid administered by qualified staff under routine circumstances.

PHOTO/VIDEO RELEASE

I grant to Organization the right to take and use photographs, video, or other media of Minor for lawful promotional, educational, archival or other purposes without payment or any other consideration. Parent/Guardian may opt out by declining below.

I consent to the use of photographs and video of Minor.
I do NOT consent to the use of photographs and video of Minor.

CONFIDENTIALITY

The parties acknowledge that certain personal and medical information disclosed in connection with Minor's participation is confidential. Organization agrees to maintain reasonable administrative safeguards to protect such information and shall only disclose it to third parties when necessary for safety, medical treatment, legal compliance, or as authorized by Parent/Guardian.

I acknowledge and consent to limited disclosures as described above.

GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to its conflicts of law principals. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

This Agreement constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, representations and understandings of the parties, whether written or oral.

REPRESENTATIONS AND CERTIFICATIONS

Parent/Guardian represents and warrants that Parent/Guardian is the natural or legal guardian of Minor, has full authority to execute this Agreement on Minor's behalf, and to the best of Parent/Guardian's knowledge the information provided in this Agreement is true and complete.

Parent/Guardian further certifies that Minor is physically and mentally able to participate in the activity and will comply with all rules, instructions and directions provided by Organization.

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