JECC/@akivaCombined Release Form Draft 10.7.17 2


PART 1 - EMERGENCY MEDICAL AUTHORIZATION (EMA)

  

 

Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

Part 1 or 2 Must Be Completed 

Part 1 Granting Consent

I hereby give consent for the following medical care providers and local hospital to be called:

       

 

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for 

(1) the administration of any treatment deemed necessary by above-name doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Facts concerning the child’s medical history including allergies, medication being taken, and any physical impairments to which a physician should be alerted:

 

Do Not Complete Part 2 if you completed Part 1

PART 2 – Refusal to Consent

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:

PART 2 - RELEASE FOR USE OF IMAGES (RUI)

I hereby give my consent to @akiva to photograph, film, videotape and then use, reproduce, and publish said images of me and/or my child/children.

 

 

I agree that photographs/negatives, film, or videotapes thereof shall constitute the sole property of the JECC and @akiva, with full right of disposition in any manner whatsoever.

I hereby release the JECC, Jewish Federation of Cleveland and @akiva from any and all claims whatsoever in connection with the use, reproduction, publication of the images thereof.

PART 3 - ASSUMPTION OF RISK, WAIVER OF LIABILITY AND INDEMNIFICATION AGREEMENT

IMPORTANT: THIS IS A LEGAL DOCUMENT, PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING

 This Agreement must be completed in order to participate in the activities associated with this program.

 

I, the undersigned, am either the Participant named above or the parent and/or legal guardian ("Guardian/Parent") of the minor Participant named above. I am familiar with the curriculum and the activities which take place in the above named course.

TERMS AND CONDITIONS

I will participate or authorize the Participant to participate in the @akiva 2017-2018 PROGRAMS. I understand that such participation can include risks that cannot be anticipated, these include illness, injury and in the rarest circumstances, death. Participant or guardian/parent freely and voluntarily participates or allows participation in the program with the knowledge of foreseeable and unforeseeable risks and hereby agrees to assume and accept any and all risk.

WAIVER, RELEASE AND INDEMNIFICATION

Participant or Guardian/Parent of Participant understands and acknowledge that the JECC, Jewish Federation of Cleveland and @akiva is not an insurer of Participant's behavior, actions or participation in the program and that JECC Jewish Federation of Cleveland and @akiva assumes no liability whatsoever for personal injuries or property damages to Participant or to third persons arising out of Participation in the Program activities. Participant or Guardian/Parent hereby agrees to release, waive, covenant not to sue, indemnify and hold harmless JECC, Jewish Federation of Cleveland and @akiva and all of their officers, employees and agents (collectively the "Releasees") from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by Participant or loss or damage to any property belonging to Participant arising out of or related to participation in the above named Program, and excepting only such loss, damage or injury as may be caused by the sole negligence of any Releasee.

If any portion of this Agreement is held to be invalid by a court of law, then it is agreed and intended that all the remainder shall, notwithstanding, continue in full force and effect.

PARTICIPANT OR GUARDIAN/PARENT OF PARTICIPANT HAS CAREFULLY READ THESE TERMS AND FULLY UNDERSTANDS THEIR CONTENT AND IS AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN PARTICIPANT OR GUARDIAN/PARENT OF PARTICIPANT AND THE RELEASEES AND SIGNS IT OF HIS OR HER OWN FREE WILL.

 I am signing this Agreement for myself as Participant. I acknowledge that I am eighteen (18) years of age and that I understand the terms of this Agreement. I also acknowledge that this Agreement shall bind my heirs and personal representatives.

 

I am signing this Agreement on behalf of a minor Participant. I acknowledge that I am the Guardian/Parent of the Participant and that I understand the terms of this Agreement. I also acknowledge that these terms shall bind my heirs and personal representatives and the heirs and personal representatives of Participant.

 

 

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Document name: JECC/@akivaCombined Release Form Draft 10.7.17 2
lock iconUnique Document ID: 3e20d9aacbcff020e6829dcda07c27b6c73f4335
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October 7, 2017 5:08 pm EDTJECC/@akivaCombined Release Form Draft 10.7.17 2 Uploaded by Amnon Ophir - aophir@jecc.org IP 107.207.104.73