BIRTHOLA, INC. Workshop, Class, or Organized Activity
CONSENT AND RELEASE FORM
AUTHORIZATION TO TREAT A MINOR
I, the parent or legal guardian of the child named below, do hereby authorize and consent to any X-ray examination, anesthetic, medical, or surgical treatment rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act or Dentist licensed under the provisions of the Dental Practice Act and on the staff of
any acute general hospital or emergency care facility from the State of California Department of Public Health. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care which the aforementioned physician, in the exercise of his/her judgment, may deem advisable for my child. Further,
I understand my child will be participating in inherently dangerous activities and agree to pay for my child's medical expenses. I understand that all effort shall be made to contact me prior to rendering treatment to my child, but any of the above treatment will not be withheld if I cannot be reached. This authorization is given pursuant to the provisions of the California Civil Code. This consent shall remain in effect for one year from the date signed for all youth activities sponsored by Birthola Inc. Outdoor Adventure Program.
RELEASE FROM LIABILITY
In consideration of the acceptance of the application of my child, as a participant in any programs and/or activities of and its affiliates, I and my child hereby agree to assume all risks attendant upon myself and my child while participating in said programs and/or activities. I and my child hereby waive, release, and discharge any and all claims for damages, death, personal injury, or property damage which I or my child may have, or which may hereafter accrue to me or my child as a result of my child's participation in an activity. I agree to indemnify and hold harmless from liability the ,Birthola Inc. Outdoor Adventure Program,
its affiliates and/or any of their agents, servants, or employees by reason of any accident, death, injury, or damages to persons or property which I or my child may suffer while participating in the said program and/or activity. This release is intended to discharge in advance the Birthola Inc. Outdoor Adventure Program
,its affiliates and/or any of its agents, servants, or employees by reason of any accident, death, injury or damages to persons or property which I or my child may suffer, from and against any and all liability arising out of or connected in any way with my or my child's participation in the said program and/or activity, even though the liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.
It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns, and the heirs and assigns of my child. I agree to assume all responsibility for any property damage or injury to any person caused by me or my child while participating in the Birthola Inc. Outdoor Adventure Program and/or activity.
I have read, understand and approve the AUTHORIZATION TO TREAT A MINOR (with restrictions I may have listed above) and RELEASE FROM LIABILITY.
Students Name (required)
Parent/Legal Guardian Full Name (required)
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