Parental Consent Signature Form

Parental Consent and Release Agreement

Recitals

WHEREAS, Parent/Guardian provides consent for the minor identified below to participate in the program, trip, activity or service described herein; and

WHEREAS, Organization requires written authorization, emergency medical consent, payment terms and release of liability from the Parent/Guardian as a condition of participation; and

WHEREAS, the parties intend that this document constitute a binding consent, release and agreement governing participation, medical treatment authorization, confidentiality of personal information and payment obligations.

Participant and Parent/Guardian Information

Minor Full Name:

Date of Birth:    Parent/Guardian Name:

Scope of Activity

Activity Start Date:    Activity End Date:

Medical Authorization and Emergency Contact

I hereby authorize authorized representatives to consent to emergency medical treatment for the minor named above if I cannot be reached:    If not authorized, check here:

Payment Terms

Participation Fee Amount: $

Late Fee for Overdue Payment:

Term and Termination

Term Commencement Date:    Term End Date:

Termination Notice Period (days):

Confidentiality and Use of Personal Information

The parties acknowledge that certain personal information concerning the minor and the Parent/Guardian may be collected and used for purposes directly related to the activity. Organization shall handle such information in a confidential manner and shall not disclose medical records, emergency contact details, or other personal data except to the extent necessary for medical treatment, legal requirement, or to fulfill the services described in this Agreement.

Consent to photograph or record: I authorize Organization to use photographs or video of the minor for internal program use and promotional materials, provided that such use does not identify the minor by personal contact information without additional consent.

Release, Indemnity and Certification

By signing below, Parent/Guardian certifies that they are the legal guardian of the minor and have authority to execute this Agreement. Parent/Guardian hereby releases and holds harmless Organization, its directors, officers, employees, volunteers and agents from any liability, claims or causes of action arising from participation in the activity except to the extent caused by Organization's gross negligence or willful misconduct. Parent/Guardian further agrees to indemnify Organization for claims arising from Parent/Guardian's or minor's negligence or breach of this Agreement.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state or jurisdiction identified below; the parties submit to the exclusive jurisdiction of the courts of that state for any disputes arising out of this Agreement.

Entire Agreement

This document constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements, understandings, negotiations and discussions, whether oral or written. Any amendment must be in writing and signed by both parties.

Acknowledgment

Parent/Guardian certifies that all information provided on this form is true and complete to the best of their knowledge and that they have read and understood the terms and conditions herein.

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