Medical Waiver and Release of Liability Form

Student FIRST and LAST name

Gender

Birthdate

Age

Grade in the Fall

Allergies/medical concerns

Parent/Guardian Information

Parent/Guardian FIRST and LAST name

Full Address (street, city, town and zip code)

Home Phone Number

Dad's Cell Phone

Mom's Cell Phone

Email Address

Contact FIRST and LAST name

Emergency contact's phone number

Physicians Name

Physician's Phone Number

Insurance Carrier

Group/Member #

I hereby grant permission for my child/student to attend Red Apple Academy. In case of accident, sickness, or injury, I grant permission to any member of the Red Apple Academy staff to see that any necessary medical assistance is rendered to my child. I also understand that, in case professional emergency treatment is deemed necessary, every effort will be made to contact me immediately, but I give my permission to proceed if I cannot be reached, so that necessary treatment will not be delayed.

I understand and agree that I will be financially responsible for any and all expenses incurred in the treatment of my child. I understand that there are certain dangers, hazards, and risks inherent in educational activities, and have signed this document in full recognition and appreciation of the dangers of these activities, which dangers include, but are not limited to, physical injuries (minimal, serious or catastrophic) and/or property loss or damage. In consideration of, and in return for, the service, facilities and other education provided to students by the personnel of Red Apple Academy, I, along with any of my assignees, heirs, and legal representatives release Red Apple Academy, The Red Apple Project, Dance Unlimited,Inc., and Saddleback Properties, Inc., and all personnel, employees, tutors, teachers, directors, and officers of these entities, from any and all liability, claims and actions that may arise from injury, harm or death to my student and from loss or damage to my student’s property in connection with these activities. I understand that this release covers liability, claims and actions caused entirely or in part by any acts or failure to act by these individuals and entities, including but not limited to negligence, mistake, or failure to supervise by these individuals or entities or any of their personnel, directors, employees, tutors, or teachers.

I authorize Red Apple Academy, at its sole discretion, to use and publish for any lawful purpose and without compensation, photographs, video, audio, and/or other depictions of registrant(s) at this program. This authorization shall remain in effect until revoked in writing.

By typing my FIRST and LAST name below I confirm that I have read the Red Apple Academy Parent/Student Handbook and will abide by and adhere to the policies and guidelines that are stated within it.