CONSENT AND DISCLOSURE FORM HOMESCHOOL

CHILD AND PARENT INFORMATION

Child/Participant’s Name:*
Birth Date:*
 / 
 / 
Parent/Guardian Name:*
Address:*
Day Phone:*
-
Alternate Phone:*
-
Person to notify in case of emergency, other than above: *
Primary Phone*
-
Alternate number:
-

Exploration Place has permission to release my child to the parent/adult contacts listed above and the following adults (18 and over) with photo ID:

Name:*
Relationship to child:*
Full Name:*
Relationship to child*

HOLD HARMLESS AND RELEASE

1. I am aware of all the inherent damages and risks involved in this Exploration Place, Inc. program including: bodily injury, sprains, fractures, dislocations, lacerations, concussions, skin disease, eye, head, neck or back injuries, or death. I give the participant the permission to participate in all activities of this program.

2. I understand that Exploration Place, Inc. does not provide any accident or medical insurance and that I agree to be financially responsible for all medical expenses whatsoever.

3. I agree, on behalf of myself, the participant, my assigns, executors and heirs, to release, indemnify and hold harmless Exploration Place, Inc. and its directors, officers, agents and employees from any and all liability, damage, or claim of any nature arising out of or in any way related to the participant’s participation in this program, except claims or losses caused by the sole gross negligence of Exploration Place, Inc.

4. I understand this agreement to be a release of all claims and causes of action for participant’s injury or death or damage to participant’s property that occurs while participating in the described activity and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by the participant’s negligent or intentional act or omission.

Parent/Guardian Signature:*