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| 2. * |
I, the undersigned and the parent or lawful guardian of (name all children who may be on site for any reason) |
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(the "Child(ren)"), will participate and give permission for my Child(ren) to participate in the educational classes and administrative duties of the cooperative (the "Activity"), and I hereby release from all liability and indemnify the Divine Mercy Homeschool Cooperative (the "Co-op"), the Instructors of each class (the "Instructors"), both individually and as instructors for the Co-op, and their respective officers, agents, representatives, volunteers, and employees, from any and all liability, claims, judgements, cost and expenses, including attorneys' fees, arising out of any injury or illness incurred by me and my Child(ren) while participating in or traveling to or from the Activity and further agree not to bring or prosecute or allow to be brought or prosecuted (including but not limited to prosecution through subrogation) in my name, or on behalf of my Child(ren), any claims, lawsuits or actions against the Co-op, Instructors, and their respective officers, agents, representatives, volunteers and employees.
a. I further understand that my and my Child(ren)'s participation in the Activity is purely voluntary and is a privilege and not a right. I elect to participate in the Activity in spite of the risks. My Child(ren), and I on behalf of my Child(ren), agree to my Child(ren)'s participation in the Activity in spite of the risks.
b. I agree to cooperate with the Co-op, Instructors, or their agents in charge of the Activity. I agree to instruct my Child(ren) to cooperate with the Co-op, Instructor, or their agents in charge of the Activity.
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| 4. |
Name of Physician, Address, Phone |
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| 5. |
Name of Dentist, Address, Phone |
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| 6. |
Name of Medical Specialist, Address, Phone |
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In the event reasonable attempts to contact an emergency contact listed below are unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring to the necessity for such surgery are obtained prior to the performance of such surgery.
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| 9. |
In the event of illness or injury requiring emergency treatment, I wish the Co-op authorities to take the following action: |
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a. I agree that the Co-op, Instructors, or their agents may use technology to communicate to me and my Child(ren) regarding educational related activities.
b. I agree that the Co-op, Instructors, or their agents may use a photograph, video, or other likeness of me or my Child(ren) ("Images") for the purpose of distributing said Images to the class parents. I agree to not share those Images on any social media accounts.
c. I agree that the Co-op may use a photograph or other likeness of me or my Child(ren) in the yearbook.
d. This acknowledgement and release is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This acknowledgement and release shall be construed in accordance with the laws of the State of Ohio except for the choice of law provisions thereof.
I have carefully read and understand and accept the terms and conditions stated herein and acknowledge that this Permission, Release and Emergency Medical Authorization shall be effective and binding upon me, my Child(ren), and my own and my Child(ren)'s personal representative or estate, assigns, heirs, and next of kin and that I have signed this agreement of my own free will.
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