Please specify, Name, Date of Birth and Contact Information to avoid delays.
Tell us about you or your situation, family dynamic, day to day life etc.
1. Consent to Participate
I, the undersigned, hereby consent for myself/my child(ren) to participate in the above program offered by Blackshear Heights Family Inc. (BHF), a 501(c)(3) nonprofit organization. I understand that participation is voluntary and that I/we may withdraw at any time.
2. Waiver of Liability
I acknowledge that participation in this program may involve certain risks. By signing below, I agree to release, indemnify, and hold harmless Blackshear Heights Family Inc., its staff, board members, volunteers, and affiliates from any liability, claims, damages, or expenses that may arise from participation, except in cases of gross negligence or intentional misconduct.
3. Medical Authorization (if applicable)
In case of emergency, I authorize BHF staff or volunteers to seek necessary medical treatment for myself/my child(ren). I assume full responsibility for any resulting costs.
4. Data & Confidentiality
I understand that any personal information collected by BHF will be used solely for program administration and will not be sold or shared with third parties.
5. Acknowledgement
By signing below, I acknowledge that I have read and understood this consent and release form. I agree to abide by program guidelines and expectations set forth by BHF.
