IMPORTANT: A signature at the bottom of this form by a parent or legal guardian is required for participation at CIMI.
EMERGENCY MEDICAL CONSENT: The Student’s medical conditions and information stated on this application is complete and correct. I give permission to the CIMI camp staff and School chaperones to, (1) administer the Student’s routine medications listed in this Application, as well as needed medications and over the counter medications for minor illness or discomfort; (2) in case of a medical emergency to provide appropriate first aid for minor injuries; and (3) seek further treatment from local physicians or hospitals if the medical condition warrants. In the event I cannot be reached in an emergency, I also give permission to the physician selected by CIMI or the School chaperone to examine, diagnose, and treat or secure proper treatment for the Student and hospitalize, and to order injection and/or anesthesia and/or surgery for the Student, as the physician shall determine proper and necessary under the circumstances. A photocopy of this Authorization shall be as valid and may be accepted as the original. This completed Application may be photocopied by CIMI and released to the physicians or hospitals if requested. This Consent is given pursuant to the provisions of California Family Code §6910. CONSENT AND RELEASE OF LIABILITY: I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of CIMI facilities, services, equipment and premises (“Facilities”) and any
participation in CIMI programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease, including but not limited to exposure to, contracting, or spreading COVID-19 or any virus. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document. In consideration of Minor’s use of Facilities and participation in Programs I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that CIMI, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs. I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited
to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees. In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs. I give permission for CIMI to use any photographs, video, or interview taken at camp to be used to illustrate, report, promote or advertise CIMI or Guided Discoveries programs or camps.