SHIFT Liability Form

Thank you for signing up!

A parent or guardian is required to fill out this form for every child who attends SHIFT. Once this form has been filled out, it does not need to be filled out again, unless your information has changed.

Child's Name *

First

Last

Child's Birthday *

(MM/DD/YYYY)

Child's Gender *

Child's Grade *

Child's Home Address *

Home Address 2

City *

State *

Zip Code *

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Cell Phone Number *

Emergency Contact Name (other than the parent/guardian) *

First

Last

Emergency Contact's Cell Phone Number *

Emergency Contact's Relationship to Child *

Please list any allergies the child has:

Please list any medications the child is regularly taking:

Please list any special instructions for the child:

In case of an emergency and BHH cannot reach me by phone, I give consent for my child to be taken to the closest hospital. I give consent by typing my name below: *

Name of Child's Primary Physician *

First

Last

Child's Primary Physician Phone *

Trusted People for Pick Up *

Rules of Behavior (read below) *

Rules of Behavior

The overseeing Leader is responsible for maintaining such behavior in the group, and has authority to direct offenders to be picked up by their parent/guardian. The parent/guardian will bear all expenses for picking up their child.

Behavior that is not tolerated includes, but may not be limited to:

- Fighting, harassment, continued coarse speech or behavior

- Possession of any weapon or dangerous object

- Possession of tobacco, alcohol, or controlled substances

- No one is to stray from the group. In the event that someone becomes separated by accident, they must make every effort to immediately rejoin the group.

- Respect for and compliance for event/facility rules

*Safe and moral conduct is mandatory for every participant at every event.

Medical Consent (read below) *

Medical Consent

As the Parent/Legal Guardian of (child listed above), I authorize Broken Halos Haven, into whose care the minor has been entrusted, to consent to medical or dental treatment and/or care. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, and is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment may deem advisable.

Parent & Child Release Statement (read below) *

Parent and Child Release Statement

As parent/legal guardian of (child listed above) I have reviewed the information about the SHIFT activity event and give my permission for the subject of this release to be involved in the overall activities listed above. I acknowledge that my child’s participation in Broken Halos Haven's SHIFT is voluntary and may require involvement in events that require traveling or physical exertion. I acknowledge that his/her participation in any Broken Halos Haven's SHIFT event presents risks that my child may suffer property damage, bodily injury, or death.

- I/we have reviewed the rules of the activity and agree that the subject of this release will abide by them. I/we also acknowledge that if the subject of this release has to return home early for any discipline violations it will be at my/our expense.

- I/we consent to the use of any video images, photographs, audio recordings or any visual or audio reproduction that may be taken of the subject of this release during the activity/event to be used, distributed or shown as Broken Halos Haven deems appropriate.

- I/we understand all reasonable safety precautions will be taken at all times by Broken Halos Haven and its agents during the events and activities. I/we understand the possibilities of unforeseen hazards and know the inherent possibility of risk. I/we agree to hold harmless Broken Halos Haven, its leaders, employees and volunteer staff for damages losses, diseases or injuries incurred by the subject of this release.

NOTE: If you desire to limit your participation in any event, please put your restrictions to Broken Halos Haven in writing in advance of the event.

The undersigned has read and voluntarily signed this release and waiver of liability and indemnity agreement, and further agrees that no oral representation, statements or inducement apart from the foregoing written agreement have been made.

By typing my name below, I give my consent to all of the above. *