In cases where medical attention is necessary, parents will be contacted for approval when possible. However, before medical treatment can be provided, we are required to have a medical release signed by the parent/guardian. The hospital will not perform services unless this form is presented at the time of treatment.

Participant has my permission to receive medical attention in the event of illness or medical emergency while participating in this Program. I will assume the financial responsibility for any cost of health care for my child that may occur during this Program.

As a participant, parent, or guardian I understand and acknowledge that my failure to disclose relevant information may result in

harm to Participant and/or others during this Program. By signing my name I represent and warrant that I have provided all materials and important information to Agility Counseling Group pertaining to my Participant’s medical, mental and physical condition and that it is accurate and complete. I agree to notify Agility Counseling Group of any changes in my mental, physical or medical condition prior to the Participant’s scheduled Program.

By revealing or disclosing the above medical information it will not be used by Agility Counseling Group personnel or employees to determine Participant’s ability to participate safely in activities. I understand that, if a Participant chooses to participate in activities, he/she does so voluntarily and of his/her own accord and the final decision regarding participation is solely the responsibility of myself and the Participant.