Registrant Information
If patient is under 18 years of age, enter guardian information below.
RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT
Green Valley Therapy Summer Camp Program
I, as the parent/legal guardian of the registrant listed above, hereby acknowledge and agree to the following:
VOLUNTARY PARTICIPATION: I consent to my child's participation in the summer camp activities including but not limited to arts and crafts, mindfulness exercises, and nature walks.
ASSUMPTION OF RISKS: I understand that participating in these activities involves inherent risks, including but not limited to:
Physical injury from arts and crafts materials
Exposure to outdoor elements during nature walks
Emotional responses during mindfulness activities
Interactions with other participants
MEDICAL CONDITIONS: I affirm that my child is physically and mentally fit to participate. I will inform staff of any relevant medical conditions, allergies, or limitations.
RELEASE OF LIABILITY: I hereby release and hold harmless [Mental Health Practice Name], its employees, contractors, and volunteers from any claims, demands, or causes of action arising from my child's participation, including negligence claims, to the fullest extent permitted by law.
EMERGENCY CARE: I authorize the staff to seek emergency medical treatment for my child if necessary. I understand I am responsible for any medical expenses.
MEDIA RELEASE: I grant permission to photograph/video my child during camp activities for promotional purposes, unless I indicate otherwise in writing.
BEHAVIORAL EXPECTATIONS: I understand my child must follow safety rules and behavioral guidelines. The practice reserves the right to dismiss participants for inappropriate conduct.
I agree to terms & conditions provided by Green Valley Therapy. By providing my phone number, I agree to receive text messages from the business with any updates regarding schedule or my child.
Emergency Contact Information