Application | Mysite 2

Application for Parent's Night Out

Child’s First name

Child’s Last name

Birthday

Month

Day

Year

Parent/ Legal Guardian Name

Address

Phone

Is the child potty trained?

Yes

Emergency Contact

Who should we call in case you cannot be reached?

Name

Phone number

Relationship to child

Primary Physician

Primary Physician’s number

Hospital of choice

Diagnosis of developmental disability

We reserve the right to request a proof of medical diagnosis

Allergies

Foods, medicines, insects, ect

Is your child prone to respiratory ailments?

Yes

If so, please describe

Has your child had seizures in the last 2 years?

Yes

If yes, when?

What cues does your child give when he/ she is getting ill?

Prescription drugs and medication dosages (if applicable)

Other medical concerns?

Sibling Information

Name and age of siblings who might attend Parents Night Out

Any allergy concerns of siblings?

How did you hear about us?

Release of Liability:

I certify that I have answered the above questions truthfully and have not withheld any information relevant to my application. I give consent for my child to participate in the Autism hope Center Parents Night Out program at Cascade Hills Church. If my child suffers an injury or illness while participating in this program, and if the volunteers of the Autism Hope Center are unable to contact me at the telephone numbers listed above, I hereby authorize the volunteers of the Autism Hope Center to obtain such emergency medical care or treatment as the medical volunteers of the Autism Hope Center deem necessary. I further consent to the provision to my child of such emergency medical care or treatment, as is deemed reasonably necessary by a licensed physician. This consent is signed for the purpose of authorizing medical treatment under emergency circumstances in my absence.

I, on behalf of my child, hereby release and waive any and all claims for damages, injury, or death against either the Autism Hope Center and Cascade Hills Church, including their officers, directors, employees, agents, independent contractors, and staff (collectively "Parents' Night Out Releases") that may accrue to me or my child as a result of my child's participation in the Parents' Night Out program, and agree to indemnify, protect, and hold harmless the Parents' Night Out Releases from any claim or liability whatsoever, including, but not limited to, personal injury, property damage, court costs, and attorney's fees, however caused, as a result of my child's participation in the Parents Night Out program, except for conduct constituting gross negligence by Parents' Night Out Releases.

I give permission to the Autism Hope Center to take/use photos of my family during Parent's Night Out for promotional purposes (print materials, newsletters, website, etc.)

COVID Release of Liability

In consideration of my child's participation in the Autism Hope Center Parent's Night Out Program, I acknowledge and agree to the following:

I am aware of the existence of the risk on my physical appearance to the venue and my child's participation to the activity of the Organization that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.

My child has not experienced symptoms that of fever, fatigue, difficulty inbreathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.

My child, nor any member(s) of my household, traveled by sea or by air,internationally within the past 30 days.

My child, nor any member(s) of my household, diagnosed to be infected ofCOVID-19 virus within the last 30 days.

I recognize that my child may be in any case be at risk of contracting COVID-19.

With full knowledge of the risks involved, I hereby release, waive, discharge the Autism Hope Center and Cascade Hills Church, its board, officers, independent contractors, affiliates, employees, representatives, successors, assigns, and from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by my child related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

I agree to indemnify, defend, and hold harmless the Autism Hope Center and Cascade Hills Church from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

Please print name to agree to the application