I, the legal guardian, do hereby give consent for my child to participate in Shine Pediatrics, LLC (dba Shine Pediatric Therapy)’s programs. I agree to release, hold harmless and waive all claims and causes of action that may hereafter accrue to me against Shine Pediatrics, LLC (dba Shine Pediatric Therapy), and any of their officers, directors, employees, agents, independent contractors, representatives, or volunteers associated with any injury that may be caused as a result of any action other than the sole negligence of Shine Pediatrics, LLC (dba Shine Pediatric Therapy), their officers, directors, employees, agents, independent contractors, representatives, or volunteers.
I further agree to indemnify and hold harmless Shine Pediatrics, LLC (dba Shine Pediatric Therapy), and any of their officers, directors, employees, agents, representatives, or volunteers, from any action or inaction of my child that may cause any injury or damage whatsoever. I hereby give full permission for my child to participate in all activities and agree to notify group leaders of any precautionary measures that should be noted or taken during group classes/camps.
I agree to pay the total class fees. I also agree to pay any additional fees that may result from a returned or invalid check or payment, etc. I understand that I may forfeit any moneys paid if my child does not attend his/her sessions.
I understand that the class(es) in which my child is enrolled will last for eight weeks. I agree that I will be present to pick my child up at least 5 minutes prior to class(es) ending.
I recognize that these classes are community-based, and fully understand that my child will NOT be receiving traditional therapy services, even if the class leader is a therapist. I understand that these classes should not replace any traditional therapy that my child receives.
In the event of any injury to my child, I hereby grant full power of attorney to Shine Pediatrics, LLC (dba Shine Pediatric Therapy), their officers, directors, employees, agents, independent contractors, representatives, or volunteers to obtain any emergency medical treatment they (in their sole discretion) deem necessary in the best interest of my child.
*Consent Valid for 12 months from date of signature.