Summer Mind Unwind Permission Slip

Summer Mind Unwind w/ Mind Body Align at The Butterfly House (20 N. Mulberry St.)

                        June 10 – June 14, 2019 from 12 p.m. to 2 p.m.

I hereby give permission for my child to participate in the ROAR summer mini module held at the Butterfly House. As a condition of being allowed to participate in the ROAR program, I agree to the following:

Liability:

I am duly aware of the risks and hazards that may arise through participation in the ROAR program, and assume any expenses and liabilities my child may incur in the event of an accident., illness, or other incapacity. If I have any questions about the ROAR program, its nature, risks or hazards, I have contacted NECIC and/or ROAR representatives and discussed those questions with him or her to my satisfaction.

In consideration of being granted the opportunity to participate in the ROAR program, I, for my child, myself, my executors, administrators, agents, and assigns do hereby release and forever discharge North End Community Improvement Collaborative, the ROAR Program, Mind Body Align, the Butterfly House, volunteers, instructors and other participants from all claims of damages, demands, and any actions whatsoever, including those based on negligence, in any manner arising out of my child’s participation in this activity. I understand that this release means that, among other things, I am giving up my right to sue for any such losses, damages, injury or costs that I or my child/ward may incur.

Media:

I hereby grant North End Community Improvement Collaborative, ROAR, Mind Body Align, and their legal representatives the absolute right and permission to copyright, use and publish images in which my child/ward may be included in whole or in part, or composite or distorted in character form, for use in published materials, illustration, promotion, art, advertising, trade, websites and any other purpose in order to promote North End Community Improvement Collaborative, ROAR programs, and Mind Body Align. I hereby waive any right that I or my child/ ward may have to inspect or approve the finished product.

Consent of Treatment:

In the event that my child/ward should, for any reason require medical or surgical treatment and/or medication during the course of his/her attendance or participation in the ROAR summer module presented by Mind Body Align, I authorize such physicians or medical staff as the organizers may appoint or designate to carry out the necessary treatment, including staff administering first aid when necessary. If my child requires an emergency room visit, I further authorize the hospital and its medical staff to provide treatments deemed necessary by them for the wellbeing of my child/ward.

Mini module your child would like to participate in: