Authorization of Consent
(I) (We), the undersigned parent(s)/guardian(s) of [PER THE NAME LISTED ABOVE], a minor, do hereby authorize any hospital for the undersigned to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and/surgeon or any X-ray examination, anesthetic, dental or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any dentist. (I) (We) hereby authorize any hospital, which has provided treatment to the above-named minor, to surrender physical custody of such minor to (our) above named agent(s) upon the completion of treatment. These authorizations shall remain effective until August 23, 2019, unless sooner revoked in writing delivered to said agent(s).
To the extent allowed by law, I, the undersigned the parent/guardian of the individual(s) named below, and shall hold harmless, indemnify, and defend I Teach Chess (ITC) Enrichment Resources/Chevelle Brown and the officers, employees, volunteers and agents of each of them from and against any and all liability, loss, damage, expense, cost of every nature, and causes of actions arising out of or in connection with any negligence in the performance of this agreement. It is further understood and agreed that this waiver, release and assumption of risk to be binding on my heirs and assigns. I also release the I Teach Chess (ITC) Enrichment Resources of liability for any claims that may arise out of activity or camp participant. I Teach Chess (ITC) Enrichment Resources also reserves the right to remove participants from the camp (to continue being billed as a participant) if they present a threat to the children or if they abuse the privilege of I Teach Chess (ITC) Enrichment Resources staff and values. I also understand that participation in the program can cause severe injury or death and I have taken care to enroll at the level of his/her physical abilities and/or medical conditions. I hereby grant permission for my child to participate on field trips aligned with the camp calendar of Great Improvement Academic Service. In addition, I grant permission for I.T.C.E.R to photograph participants while participating in the activities to use for publicity. One parent/guardian must sign for all minors. I have read this entire Informed Consent Agreement. I fully understand it and I agree to be legally bound by it.