Student Waivers (under 18) | Whole Children - After school and Saturday programs for children and teens of all abilities, including those with special needs

Student's Name *

First

Last

Date of birth: *

Parent/Guardian Name (printed): *

First

Last

GENERAL LIABILITY WAIVER. I recognize the potential for injuries which can occur in activities involving movement and exercise. I have consulted with my child’s healthcare provider regarding her/his participation and I hereby consent to her/him participating in activities on equipment owned or used by Pathlight, Inc. In addition, I agree that brief physical contact by teachers and/or staff is permissible to a) promote student safety, b) provide physical guidance or prompt when teaching a skill, c) redirect attention, d) provide comfort, or e) use to provide physical escort. I hereby agree that I, for myself, my child(ren) adopted or otherwise, my heirs and executors waive and release any and all rights and claims for damages that I may have at any time against Pathlight, Inc. or its agents and representatives, for any injuries or damages in connection with my association with or entry in any activity sponsored by Pathlight, Inc. *

Parent/Guardian Signature

Today's Date:

TRAVEL PERMISSION WAIVER. I hereby give permission for my child to be transported by Pathlight, Inc. staff and drivers. I hereby agree that I, for myself, my child(ren) adopted or otherwise, my heirs and executors, waive and release any and all rights and claims for damages that I may have at any time against Pathlight, Inc. or its agents and representatives, for any injuries or damages in connection with transportation by Pathlight, Inc. staff. *

Parent/Guardian Signature

Today's Date:

VIDEO AND PHOTOGRAPHY WAIVER. I do or do not (please select one) consent to have my student photographed and/or videotaped while participating in classes and programs at Pathlight’s Whole Children and Milestones Recreation programs. I understand that the photos and videos may be used for educational purposes, or for publication, including use on the internet. *

I give consent
I do no give consent

Parent/Guardian Signature

Today's Date:

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