In consideration of my minor child’s participation in the Loma Linda University Medical Center East Campus PossAbilities Triathlon described herein, and having actual knowledge and appreciation of the particulars of the program and those risks involved in this type of activity/program, I voluntarily consent to my minor child’s using these facilities and participating in the activities/programs at this site, and assume all the risks arising there from.
Date: December 11, 2016
Activity/Program: Children’s Christmas Party
Location: Loma Linda University East Campus
Description: Community event
RELEASE OF LIABILITY AND WAIVER OF CLAIMS. I, for myself and my personal representatives, assigns, heirs, and next of kin, hereby RELEASE, HOLD HARMLESS, WAIVE, DISCHARGE AND COVENANT NOT TO SUE, the officers, trustees, faculty, employees, representatives, agents, students, and volunteers of Loma Linda University Medical Center, Loma Linda University and their affiliated entities (the “Releasees”), from liability, claims, demands, losses or damages including personal injury, property damage, or otherwise, caused or alleged to be caused in whole or part by negligence, active or passive, of the Releasees that arise out of my minor child’s participation in the herein named activity/program.
CONSENT FOR MEDICAL TREATMENT. In the event of sudden illness, accident or injury which may occur while said minor is engaged in the PossAbilities Triathlon, I hereby authorize and consent to any appropriate medical care provided by any licensed physician, emergency room staff, licensed dentist, or other health care provider. I understand this authorization to provide advance consent to render care which the health care provider in the exercise of his/her best judgment may deem advisable. I understand that every reasonable effort shall be made to contact the undersigned prior to rendering treatment to the minor patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I further acknowledge that I am on actual notice that Releasees have no medical, health or hospitalization insurance to cover me or my minor child in the event of an accident, injury, illness or death.
I hereby declare and represent that in making, executing, and tendering this Statement of Voluntary Consent and General Release, I fully understand and acknowledge that I am relying wholly upon my own judgment, belief and knowledge of the circumstances involved in my minor child’s participation at the described activity/program, and that I have read this statement, understood its contents and voluntarily executed it of my free will and choice.
CONSENT TO BE PHOTOGRAPHED. My digital signature gives you permission to take photographs of me and those named in my registration to serve the best interests of Loma Linda University Health or any of its divisions or schools.