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The undersigned(s)
being the lawful parent(s) and/or guardian(s) of the above named minor child (the "Child") or the participant, being of legal
age, hereby consents to the participation by the Child and/or Participant in The Huntington’s
Disease Society of America’s - Illinois Chapter National Youth Alliance Weekend Retreat (activity) conducted by
The Huntington’s Disease Society of America – Illinois Chapter National
Youth Alliance (organizer) and to the participation of the Child and/or Participant in all events relating to the activity
on August 21, 2009 through August 23,
2009.
The undersigned
hereby further authorize(s) any of the staff, employees, agents and representatives of Organizer to provide for, approve and
authorize any health care at any hospital, emergency room, doctor’s office or other institution; employ any physicians,
dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the
contents of any medical records; execute any consent form required by medical, dental or other health authorities incident
to the provision of medical, surgical or dental care to the child. Health care shall include but not be limited to the administration
of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures.
If there is
no medical emergency, the guardian (Organizer) will first use reasonable efforts to contact the parent(s) and/or guardian(s)
before administering or authorizing any treatment.
Notwithstanding
other provisions in this Consent Form, Organizer shall not have the authority to withhold or withdraw life-sustaining
procedures for the Child.
The undersigned
assume(s) all risk of injury or harm to the Child associated with participation in the Activity and agree(s) to releases,
indemnify, defend and forever discharge the Organizer and its staff, employees and agents (collectively the "Organizer"),
Lake LaDonna Campground, it’s owners and all employees of and from all liability, claims, demands, damages, costs, expenses,
actions and causes of action (collectively the "Claims") in respect of death, injury, loss or damage to the Child or by the
Child, howsoever caused, arising or to arise by reason of or during the Child's participation in the Activity.
This Consent
Form may be revoked at any time before the expiration date with written notice to Organizer.
Signed on ________________
(date), at _______________________ (city), _______________ (state).
________________________________
Signature of
Parent
________________________________
Signature of
Parent
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