I-/We give permission for the child whose name is referenced above (the Child) to participate in Created the Stars Prom 2018, a prom event sponsored by the Piedmont Triad Church, Inc. (the Church). Created the Stars Prom 2018 includes the prom event and the overnight accommodations for the prom event arranged for the Child through the Church (the Activity). In agreeing to this release, I/we hereby waive all claims, to the extent permitted by law, against the Church and their employees, Board members, agents, members, and other persons or entities who lead or direct these activities and the host family providing overnight accommodations, in the event of injury, illness, accident, or death which may hereafter -arise out of or in connection with the Child's participation in the Activity. By agreeing to this release, I/ we also hold harmless, exempt and relieve the persons and entities mentioned above from liability for personal injury, property damage, or wrongful death, whether arising out of carelessness, negligence or otherwise.
If it becomes necessary for the Child to receive medical attention or treatment while participating in the Activity, I/we hereby authorize the person(s) leading or directing the Activity or the host family responsible for my child's accommodations to use their best judgment in obtaining medical attention or treatment for the Child's benefit.
I/We further authorize the physician or other medical personnel or facility that is selected by the person(s) leading or directing the Activity or the host family to render medical attention or administer medical treatment to the Child as that physician or other medical personnel or facility deems appropriate and necessary, including the exchange of confidential information when there is an imminent danger to the health and safety of the Child. I/We understand that none of the above-named persons or entities will provide or guarantee insurance coverage for medical or hospital costs for the Child, which arise during the course of the Activity and that any costs incurred for such medical attention/treatment will be my/our sole responsibility.
Please initial the following to certify:
I/we have disclosed above any and all allergies for the Child including, but not limited to, nut, egg, dairy, shellfish, or gluten.
I/we have disclosed above any cognitive or medical needs for the Child with specificity.
By entering my full name below, I/we am/are electronically signing this waiver and release and, am/are certifying I/we have disclosed any medical needs, cognitive needs, allergies, or additional special needs as it relates to the Child.