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PARTICIPANT CONSENT, RELEASE AND ASSUMPTION OF RISK


Trailblazing Hope Outdoors adventure programs involve a variety of activities. Some programs may include rigorous physical activities such as backpacking, paddling, climbing (outdoor & indoor), biking, whitewater rafting, swimming or hiking. These activities are designed to be within the physical, mental and emotional limits of a person in reasonably good health. The level of participation in all programs and activities is at all times completely up to the individual.

I acknowledge that my participation in backpacking, paddling, biking, whitewater rafting, swimming, hiking, climbing (outdoor & indoor), and/or individual and group activities of any kind entail known and unanticipated risks that could result in physical or emotional injury or death. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I expressly accept and assume all of the risks existing in any activity. My participation in any activity is voluntary, and I state that I elect or will elect to participate in spite of the risk.

In consideration for being allowed to participate in Trailblazing Hope Outdoors activities and trips, being fully aware of the nature of the risks and hazards of participation in Trailblazing Hope Outdoors activities including but not limited to the possibility of physical or emotional injury, death, or loss of or damage to personal property, I do knowingly and willingly release and hold harmless TRAILBLAZING HOPE, INC. and its officers, agents, sponsors, volunteers, and employees and all persons associated in any way with TRAILBLAZING HOPE, INC. from any claims, causes of action or liability for property damage and/or physical injury or death in connection with or during any Trailblazing Hope Outdoors activity. This release is made on behalf of myself and/or my minor child and my/his/her heirs, representatives, executors, administrators and assigns.

I further consent to the use of any photographs (motion or still) or any records of my likeness, or that of my minor child, which may be taken or made by Trailblazing Hope Outdoors representatives with the understanding that such photographs or recordings are for Trailblazing Hope Outdoors publicity or promotional purposes only and not for commercial distribution.

By signing this document, I agree that if I or my minor child is hurt or property is damaged during participation in Trailblazing Hope Outdoors activities, I waive my right to bring or maintain a lawsuit or claim against Trailblazing Hope Outdoors. I also acknowledge that I have fully satisfied myself as to the nature of the activity or activities in which I or my minor child will be participating, the risks associated with each such activity and my responsibility to know my or my minor child’s limits. I assume all these risks. In the event of illness or injury, I hereby give my consent to provide emergency medical care including hospitalization, anesthesia, surgery, injections of medication (including epinephrine) or other treatment that may become necessary.

I have had sufficient opportunity to read this entire document. I have read and understand it, and I agree to be bound by its terms.

Today's Date: September 28, 2022


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*

I certify that I am the parent/legal guardian for Minor who desires to participate in Trailblazing Hope Outdoors, INC activities. I affirm, under penalties for perjury, that I am my minor child’s parent or legal guardian and I consent to my child’s participation with Trailblazing Hope Outdoors activities and that I have read the above and understand its meaning and agree to be bound by its terms.




By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

HEALTH QUESTIONAIRE

The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A Trailblazing Hope Outdoors ADVENTURE.


Height

Weight
Do you have any limiting physical or health disabilities, temporary or permanent, that you or your Doctor feel would limit your participation in a Trailblazing Hope Outdoors activity?*
No
Yes

If yes, please explain
Do you require any mobility, sensory or cognitive accommodations to participate in this program?*
No
Yes

If yes, please explain
Are you currently pregnant?*
No
Yes
Are you currently taking any medications?*
No
Yes

If yes, please list medication(s) and reason for taking the medication
Are you allergic to any medications including over the counter medications?*
No
Yes

If yes, please explain
I give my permission to the staff of Trailblazing Hope Outdoors to administer over the counter medications, Yes No expect as noted above. For minor children over the counter dosages will be determined by the age and size of the child as noted on the bottle, unless otherwise indicated by parent/guardian.*
No
Yes
Do you have or have you had a history of: (please check all that apply)
Asthma
Diabetes
Allergies (Food, Insects, Animals, Medication)
Blood Disorder
Infectious Disease
Heart Disease or History
Seizures
Food Intolerances
Ear Problems
Eye Problems
Orthopedic Problems
Diagnosed ADD or ADHD
Other

If 'other'

Please explain health problem checked above (including: PROBLEM, WHAT WE WILL SEE, TREATMENT, and LIMITATIONS)
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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