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Mid South

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:

  • This agreement releases Little Medical School from all liability relating to injuries that may occur during participation in any of our classes or activities, including but not limited to the use of equipment such as stethoscopes, mortars and pestles, blood pressure cuffs, stuffed toy/plush or any other educational tools provided. By signing this agreement, I acknowledge the inherent risks involved in these activities and agree to hold Little Medical School entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence or otherwise.

  • USE OF STETHOSCOPE (where applicable for certain classes)

  • I acknowledge the risks involved in using a stethoscope. These include but are not limited to ear infections, blown ear drums, wrapping stethoscope around neck, and yanking of stethoscope causing injury. I swear that I am participating voluntarily, and that all risks have been made clear to me. Additionally, I do not have any conditions that will increase my likelihood of experiencing injuries while engaging in this activity. By signing below I forfeit all rights to bring a lawsuit against Little Medical School for any reason. In return, I will receive a stethoscope. I will also make every effort to obey safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.

  • IDENTIFICATION & ASSUMPTION OF RISK:

  • 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.

  • CONSENT TO PHOTOGRAPH, INTERVIEW, AND/OR AUTHORIZE THE 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, trade show displays, and social media. 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.

  • ACKNOWLEDGEMENT OF UNDERSTANDING:

  • 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.

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