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This waiver provides permission and waives liability for my child to participate in learning activities with Capital Experience Lab & Primeability.

Permission and Waiver

Program & Activity Participation 

I agree to permit the child(ren) named to participate the learning program and activities sponsored by Capital Experience Lab and Primeability. I understand that the child(ren) will be under Capital Experience Lab and/or Primeability supervision throughout the duration of the program.

Field Trip Transportation and Supervision

I agree to permit the child(ren) named to participate in walking trips, field trips and other activities sponsored by Capital Experience Lab and Primeability. This permission is given with the understanding that transportation, if needed, will be provided by walking or public transportation. I also understand that the child(ren) will be under Capital Experience Lab and/or Primeability supervision throughout the duration of any trip.

Safety

Knowing there is a certain amount of risk involved in even the simplest of children’s games and activities, I give my permission for my child to participate in activities and programs hosted by Capital Experience Lab and Primeability. I accept responsibility in the unlikely event that an accident might take place. I hereby certify that I carry health and/or accident insurance for my child and that I am solely responsible for the cost of health care for my child, even as a result of my child’s participation in Capital Experience Lab and Primeability joint programs or activities.

 

I agree that Capital Experience Lab and Primeability, their employees (both paid and volunteer), Board of Directors and affiliated agencies, shall not be liable for any claims, demands, actions or causes of action, whatsoever for any injury caused to me or to my child as a result of my child’s involvement in Capital Experience Lab and Primeability programs or activities.

RELATING TO CORONAVIRUS/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Capital Experience Lab and Primeability have put in place preventative measures to reduce the spread of COVID-19; however, Capital Experience Lab and Primeability cannot guarantee that individuals who attend events in person with Capital Experience Lab and Primeability will not become infected with COVID-19. Further, participating in events in person may increase your risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child may be exposed to or infected by COVID-19 by engaging in activities through Capital Experience Lab, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Capital Experience Lab may result from the actions, omissions, or negligence of my child and others, including, but not limited to, Capital Experience Lab employees.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my participation in any activity held by Capital Experience Lab (“Claims”).

I hereby release and covenant not to sue, discharge, and hold harmless Capital Experience Lab, its employees, agents, volunteers and representatives, of and from Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Capital Experience Lab or Primeability, their employees, agents, volunteers and representatives, whether a COVID-19 infection occurs before, during, or after participation in events or any activity held by Capital Experience Lab and Primeability.

I understand the implication of this Permission and Statement of Release. I certify that I am legally capable of executing this agreement, and that I have done so of my own free will on the date indicated below, on behalf of myself, my spouse, if not signed separately, and our child(ren).

 

I hereby expressly forever relieve and discharge said Capital Experience Lab and said Primeability from all acts of negligence on the part of Capital Experience Lab, its employees (both paid and volunteer), the corporation, its servants, agents, officers, shareholders and affiliated agencies and from all acts of negligence on the part of Primeability, its employees (both paid and volunteer), the corporation, its servants, agents, officers, shareholders and affiliated agencies.

 

Authorization for Medical Care

In case of serious accident of illness to my child or in the event that the injury/illness involves my child’s mouth or teeth, I hereby authorize the staff of Capital Experience Lab or the staff of Primeability or my child’s physician or dentist to give any necessary treatment to my child. You may call the doctor and/or ambulance if necessary. I agree that I am solely responsible for updating medical information to Capital Experience Lab and Primeability.

 

I understand the implication of this Permission and Statement of Release. I certify that I am legally capable of executing this agreement, and that I have done so of my own free will on the date indicated below, on behalf of myself, my spouse, if not signed separately, and our child(ren).

September 17, 2021

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information and updates about CapXLab by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you attended CapXLab programming before?
Yes
No

Emergency Contact Name *

Emergency Contact Relationship to Participant *

Emergency Contact Phone Number *
Participant Race/Ethnicity
Asian American / Pacific Islander
Black or African American
Hispanic or Latino(a)
Native American or American Indian
White
Other
Prefer not to report
I give permission for Capital Experience Lab to publish or share photographs of my child for publicity, recruiting, or web content.
Yes.
No, I do not give permission.
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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