The parent, legal guardian, or foster parent of the above-named minor, hereby give my permission for his/her participation in the youth Activity named above. I have directed my child to cooperate and conform to directions and instructions of persons responsible for the activities.

In signing this form, I warrant and represent that I am the parent, legal guardian, or foster parent, that I am 18 years of age or older; and I indemnify and hold harmless, release and discharge Help One Child and Union Presbyterian Church and their constituent organizations, officers, agents, employees, and volunteers from any and all claims for personal injuries, property damage or wrongful death that my child may suffer as a result of his/her participation in the activity described above, whether or not such injuries or damages are caused by the negligence (active or passive) of any of the entities or individuals named or described above.

I agree that in the event my child is injured as a result of his/her participation in the above-named activities, including transportation to and from these activities, recourse for the payment of any hospital, medical, dental, or related costs and expenses will be paid either by me or my spouse, accident, hospital or medical insurance, or any available benefit plan of mine or my spouse.

I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician, surgeon, or dentist licensed under the Medical Practice Act and Dental Practice Act. As parent, legal guardian, or foster parent, I am responsible for the health care decisions of my child and am authorized to consent to services to be rendered, and law requires no other consent.

I hereby give permission to the physician selected by the Activity supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist.

I hereby authorize the making of photographs, motion pictures, videotapes, recordings, or other memorializing of said event and his/her participation therein.

I acknowledge that the stated Activity hours and date listed on the Event Sign-up Page. I specifically agree that in retrieving my child I will arrive in a timely fashion (or earlier by arrangement). If for some unexpected reason I am unable to comply, I will immediately get in touch with the following on-site contact to make arrangements for my child to remain with this authorized individual until I am able to return:

Melanie Hohengasser, Events & Programs Manager
HELP ONE CHILD
(408) 731-0739

Valerie Crane, Director of Support Services
HELP ONE CHILD
(408) 221-0791