TreeHouse Release Form

Release and Indemnification Agreement

Name of Person Filling Out This Form *

Parent/Guardian Email *

Youth Information

First Name *

Last Name *

Date of Birth *

Month *

Day *

Year *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Parent/Guardian Information

Parent/ Guardian Name #1 *

Parent/ Guardian #1Cell Phone

Parent/ Guardian Name #2

Parent/ Guardian #2 Cell Phone

Medical Information

Health Insurance Provider

Policy Number

Date of Last Tetanus Vaccination

Allergies/Medical Conditions

Doctor’s name

Phone

Preferred Hospital

PERMISSION/RELEASE
I certify that my child is in good health, free from communicable disease, and able to participate in all activities. I give The Well-TreeHouse permission to treat my child for routine medical care if needed. In case of emergency, I give permission to the physician/hospital to secure proper treatment for my child as named above. I voluntarily agree to assume all risks related to my child’s participation in this program, trips and activities. I hereby release and do not hold responsible The Well-TreeHouse staff and volunteers from any loss, liability, damage or costs including medical, court costs, and attorney fees that may be incurred due to my child’s participation in this program. It is my intention to release The Well-TreeHouse from all liability or responsibility for personal injury, property damage or wrongful death as a result of my child’s participation or as a result of the negligence of the released parties, whether passive or active.

AGREEMENT TO TRANSPORT
I authorize my student to ride in The Well-TreeHouse vehicle or staff/volunteer assigned vehicle when transport is needed for program, including mentoring. I understand that The Well-TreeHouse staff and volunteers may need to send a student home as a result of illness or discipline problems. I understand if my child is dismissed from the program, trip, or activity, he/she will be transported home at my expense. The Well-TreeHouse staff and volunteers will attempt to contact the parent or guardian to arrange such transportation.

MEDIA PERMISSION
I give permission to The Well-TreeHouse and anyone authorized by The Well-TreeHouse to use my student's likeness and/or voice for future promotional/social media/and representation of the ministry. Any questions or concerns prior to signing this document, please reach out to deb@scottcountytreehouse.org or 952.412.4430. The consent box below represents my acknowledgment and agreement.

Consent *

Yes, I acknowledge and agree with this release and indemnification agreement.

Please do not fill in this field.