Waiver and Release of Liability and Media Release Waiver

Parent/Guardian's First Name:

Parent/Guardian's Last Name:

Parent/Guardian's Phone Number:

Child's First Name:

Child's Last Name:

Physician's Name:

Physician's Phone Number:

Any Known Allergies?

Any Physical Limitations or Other Needs?

Check the box to accept these terms and conditions

As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor participant. I understand the nature of the activities that my child will be participating in during the week of Camp Paw Print at the Flagler Humane Society (FHS). I also understand the nature of domestic shelter animals and that their behavior is sometimes unpredictable which can give rise to risks such as personal injury. Knowing this, I, and anyone who might claim on my behalf, release the FHS, it's officers, directors, staff, volunteers and all others affiliated with the FHS from any and all claims and liability of any kind arising out of personal injury and property damage resulting from my child's participation in activities during Camp Paw Print. I authorize the FHS to seek proper medical help at my cost. I have no knowledge of any medical condition that would prevent my child from participating in the activities at FHS's Camp Paw Print I give my permission for my son/daughter to participate in the field trips. I understand that although the students will be supervised by (FHS staff and volunteers), I do assume the risk in my student’s participation in the event. I acknowledge that I will not seek to have FHS held liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of my son’s/daughter’s participation in the field trip. This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from my child’s participation in the event. I hereby release and agree to hold harmless Flagler Humane Society, its officials, agents and employees, from any claims arising out of my son’s/daughter’s participation in the event(s). I have read and understand and accept all of the statements recited above and accept full responsibility as described.

Media Release:

I understand and agree that the FHS may use my child's name, videos, audio or photography in which my child appears for publicity or promotional purposes for the Flagler Humane Society without any liability or obligation to me or my child. All photographs are video/audio recording are property of the Flagler Humane Society. I have read and understand and accept all of the statements recited above and accept full responsibility as described.

Medication Release Form

No medication will be administered by the camp staff without written authorization of a physician and/or parent. Medicine must be kept in original container and must be labeled.

Child's Name

Name of medicine

Date to start

Date to finish

Acceptable to be administered under these circumstances

Amount to be administered per dose

My child has had this medicine before

Yes No

They had a reaction to this medicine

Yes No

If yes, please give details of the reaction