In the event there is an emergency related to your child, please provide at minimum 1 person whom you would authorize to act on your behalf if we were unable to reach you.
In the event of an emergency I authorize the emergency contact person(s) listed above to act on my behalf when you are unable to reach me.
In the event that my child may require medical, dental and/or surgical care while I am unable to be reached, I hereby give my consent for medical, dental and/or surgical treatment. I agree to pay all costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent.
(1) I hereby understand that my child personally assumes all risks in connection with participation in United Action for Youth programming and hereby releases waives and forever discharges United Action for Youth and their employees, agents, volunteers and representatives (Releases) from any and all liability of any and every nature whatsoever, including claims or suits at law or in equity that I may have, for any and all personal injury. Including death, and property loss or damage that may result from, arise out of, or be related to my participation in the programming, including any travel to and/or from the program site. I hereby agrees to indemnify and hold harmless the Releasees from such liability whether injury, loss or damage is caused by my negligence, the negligence of the Releasees, or the negligence of any third party.
(2) United Action for Youth may take photographs, videos and/or audio record my image and/or voice to use in promoting the purpose of the program. I understand that no financial benefits from the use of the photographs, videos and/or audio record are obligated to be paid to me.
I have read this emergency medical treatment consent form, release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.