Waiver of Liability - Little Medical School

Please complete the form below upon registration. For any questions or concerns, please contact us at seattle@littlemedicalschool.com.

READ THIS FORM CAREFULLY BEFORE AGREEING. THIS IS A GENERAL RELEASE AND INDEMNIFICATION OF CLAIMS.

Consideration: I acknowledge the personal benefits accruing to my child by reason of participation in this camp and am aware of the activities which my child will be involved through said participation.

Release/Indemnification*

I agree.

I hereby, in consideration of such benefits, consent to the participation. This agreement releases Little Medical School Seattle from all liability relating to injuries that may occur by using a stethoscope. By signing this agreement, I agree to hold Little Medical School Seattle entirely free from any liability including camp location, its directors, employees, agents, volunteers, and affiliates from any and all present or future liability, claims, demands, actions, or rights of action, whether asserted by me or a third party arising out of my child's participation in the event activities (the "Claims"). I agree to indemnify and hold harmless Little Medical School Seattle and camp location for any such Claims brought by me or a third party from any costs associated with defending or litigating such claims, including but not limited to attorney fees, costs, and legal expenses.

Assumption of Risk*

I agree.

I am aware of the risks associated with participation in the above event and do hereby voluntarily assume full responsibility for any risk of loss, property damage, or personal injury, including death, that may result from participation in the event activities.

Technology Authorization Addendum:*

I agree.

I acknowledge that during my child's participation in the Summer Camp that certain risks do exist. These include, but are not limited to, the hazards of handling electronics and risks associated with access to the Internet including viruses/Malware and the risk of inadvertently viewing adult content. In consideration of this acknowledgment, I voluntarily have and do hereby, assume all risks associated with my child's participation in these programs.

WAIVER OF LIABILITY*

I agree.

This agreement releases Little Medical School Seattle from all liability relating to injuries that may occur by using a stethoscope, mortal pestle, blood pressure cuff, or any equipment used in particular classes. By signing this agreement, I 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.

Stethoscope Authorization Addendum*

I agree.

I acknowledge the risks involved in the use of a stethoscope. These include but are not limited to ear infections, perforated eardrums, wrapping stethoscope around the neck, and yanking of stethoscope causing injury. I acknowledge 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 this agreement, I forfeit all right to bring a suit against Little Medical School Seattle, for any reason. In return, I will receive a stethoscope in certain classes only. 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.

CONSENT TO PHOTOGRAPH, INTERVIEW, AND/OR AUTHORIZE THE RELEASE OF INFORMATION

I agree.

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, social media platforms, 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 Seattle. 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 the 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.

CONSENT TO PHOTOGRAPH OPT OUT

I would like to opt out of having my child's photograph taken

Revocation*

I agree.

I understand that I have the right to revoke this authorization in writing at any time by written request to Little Medical School Seattle. But the revocation will not be effective to the extent that Little Medical School Seattle 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 understand that Little Medical School Seattle will not condition me and/or my child’s participation on whether I sign this consent and authorization. I have read and understand the terms of this Consent.

Understanding*

I agree.

I represent and acknowledge that I have completely read and understand this document and all its terms, and all matters referred to herein, and I signed voluntarily as my free act and deed, that I have had ample opportunity to obtain the advice of counsel and that, by signing this document, I understand that I am relinquishing legal rights and remedies that may have otherwise been available to me. I understand that this Waiver and Release shall be construed as broadly and inclusively as is permitted by applicable law and agree that if any portion of this document is held invalid; the remaining shall continue in full force and effect. To the extent the restriction on filing lawsuits is deemed unlawful, I agree to submit any Claims to a mediation
organization for binding resolution.

Submission of this form is evidence of my voluntary consent and authorization for the publication of visual images and/or audio recordings of me and/or my child by Little Medical School Seattle.

Name of Participant(s)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Participant(s)' Parent/Guardian Name:

First Last

Date

Student's Name*

First Last

Student's Age*

Camp(s) Name*

Camp(s) Dates*

CAPTCHA