Children's Program Participant Form

I voluntarily consent to allow the child or children listed in this application to participate in the Hanley Foundation Children's Program. I further voluntarily consent and agree to participate myself.  I am aware that participation in the Children’s Program involves certain activities (such as physical activities including swimming) which are physically demanding and potentially dangerous for children. I am aware that these activities involve a potential risk for illness and injury to my child and property.  I acknowledge that I am aware of and assume all risks and wish to allow my child to participate in the activities. I acknowledge that I am responsible for informing Children's Program staff of any allergy, injury, or other physical or mental health condition that might be relevant to my child's or children's participation in the program.As part of the consideration for my child’s participation, I agree to assume full responsibility for any loss, injury, or inconvenience that my child might suffer.  To the extent that I participate in such activities, I further agree to indemnify and hold harmless Hanley Foundation and all its subsidiaries and officers from any and all liability incurred as a result of participation by myself or my child.  I also agree that the terms hereof shall serve as a release and assumption of risk for my heirs, executors and administrators, and for all members of my family.

In the event I cannot be reached in an emergency, I hereby give permission to the person named as emergency contact to authorize medical and hospital care of my child and if such person cannot be reached, I give permission to the physician on-call at the treating Medical Center to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child(ren) as named above. I give permission for Hanley Foundation staff or any treating medical provide to contact the primary medical provider listed above in order to coordinate care for the child(ren) listed in this application.

I understand that participation in the Children's Program will involve my child(ren) being transported by motor vehicle from the Hanley Resource Center to the Hanley campus. I authorize this transportation.