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Waiver, Release, & Consent Form

This form is required for any student participating and/or volunteering in Little Medical School activities, events, and programs. You will not be permitted to participate in Little Medical School events without this form electronically signed by a parent or legal guardian. (You may request a hard copy to sign and return.)

  • MM slash DD slash YYYY
  • Participant Information:

  • Child's NameDate of Birth (MM/DD/YYYY)Age 
    Click the plus sign to add an additional child.
  • Parent / Legal Guardian Information


  • RELEASE & WAIVER OF LIABILITY: In consideration for my child’s participation in Little Medical School, I hereby release, waive, discharge, and covenant not to sue Little Medical School (“LMS”), its franchises, representatives, employees, agents, and volunteers (hereinafter referred to as “Releases”) from any and all liability (including financial responsibility), claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or any injury that may be sustained by my child, or to any property belonging to me or my child, whether caused by the negligence of the releases or otherwise, while participating in the Little Medical School, or while in, on or upon the premises where the LMS is being conducted. LMS Activities may include, but are not limited to the following: • General outdoor and indoor inclusive but not limited to running, jumping, stretching and walking • Interactive classroom projects • Real medical tools and equipment used in particular activities, events, and programs including but not limited to stethoscope, reflex hammer, retractable measuring tape, mortal pestle, and blood pressure cuff.

  • IDENTIFICATION AND ASSUMPTION OF RISK: Participation in the activity, as well as utilization of LMS facilities, carries with it certain inherent risks and potential hazards that cannot be eliminated regardless of the care taken in LMS, including but not limited to, risk of damage, loss, and theft of personal property, as well as injuries (including death) associated with activities and other injuries that may not be foreseeable. The specific risks vary from one activity to another, but the risks could include, but not be limited to, 1) minor injuries from physical activity including but not limited to scratches, bruises, and sprains 2) injuries from use of medical tools and equipment including but not limited to ear infections, blown ear drums, wrapping stethoscope around neck, and yanking of stethoscope causing injury 3) thefts and criminal intrusions. I have read the previous paragraphs and I know, understand, appreciate these and other risks are inherent in LMS. I hereby elect to voluntarily participate in LMS, and engage in such activity knowing that there may be hazardous to my child and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, that may be sustained by my child, or any loss or damage to property owned by me, as a result of my child being engaged in LMS, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASES or otherwise. By signing below, I forfeit all rights to bring a lawsuit against Releases for any reason. I will also make every effort for myself and my child to obey safety precautions as listed in writing and as explained to me and/or my child verbally. I will ask for clarification when needed.

  • MEDIA CONSENT and/or AUTHORIZATION FOR RELEASE OF INFORMATION: I consent and authorize to take photographs, video, or other visual images of me and/or my child and/or to record me and/or my child’s voice, the results of which may be published into the public domain in print, visual, or electronic media including, but not limited to: brochures, direct mail, advertisements, newspapers, newsletters, magazines, television, radio, presentations, web sites, and trade show displays. I understand that the visual images or audio recordings may make me and/or my child’s identity recognizable. I agree that all reproduction and all copyrights associated with the above described media shall remain the property of Little Medical School. I understand that the use of the communications efforts may directly or indirectly benefit the program financially. I agree that my child and/or I are not entitled and release any right to any claim my child and/or I may have related to use of my and/or my child’s visual images and/or audio recordings, including but not limited to, any claim for payment or royalty in connection with distribution or publication of these communications. I understand that I have the right to revoke this authorization in writing at any time by written request to Little Medical School. But the revocation will not be effective to the extent that Little Medical School already relied on my authorization; for example, the revocation will not apply to publications already in production nor will it apply to publications already distributed to the public. Otherwise, the authorization will remain in effect for 5 years or until the media utilizing the photograph(s) or interviews are no longer in use, whichever occurs later.

  • I have read the waiver of liability, assumption of risk, indemnity agreement, media consent and authorization of release of information; fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing this agreement freely and voluntarily, and intend by my signature to be complete and unconditional release of all liability to the greatest extent allowed by law.

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