Cerebral Palsy Week Camper Application

Nicklaus Children's Hospital Consent for Photography, Video/Television, Audio/Sound Recordings and Interviews*:

I hereby give my consent and authorization to Nicklaus Children’s Health System, Nicklaus Children’s Hospital, and Nicklaus Children’s Hospital Foundation, including its physicians, authorized technicians, employees, and authorized agents (collectively “NCHS”) to photograph, film, create digital images, video, interview, create sound recordings, or otherwise create media content (“Content”) of me/my child related to the event identified above or treatment of my/my child’s medical condition(s), including any operative or special procedures performed, for the purposes indicated in this consent.

I understand that such media content may include my/my child’s face, image, likeness, voice, name, age, any and all information regarding my/my child’s medical condition(s), treatment, status, prognosis, and other protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA) as amended, and other federal or state privacy laws. I hereby consent to and specifically authorize NCHS to disclose and use such Content as indicated:

Marketing or Media Purposes*:

The Content may be used by NCHS for internal and external marketing, public relations, communications, and promotional purposes. Disclosures may be made to national and local reporters, television programs, news agencies, radio stations, internet, and social marketing or media sites.

Waiver of Liability and Hold Harmless Agreement:

In consideration of participation in this Nicklaus Children’s (“Event”), I, the undersigned, for myself/as the parent/guardian of a minor(s) (collectively “Minor”), agree to indemnify and hold Nicklaus Children’s Health System, Nicklaus Children’s Hospital, Nicklaus Children’s Hospital Foundation, and its affiliated entities, and their respective employees, agents, directors, officers, and other representatives (collectively, “NCH”) harmless and hereby waive, release and discharge any and all known and unknown, foreseen and unforeseen claims, demands, rights and causes of action for damage, death, personal injury, bodily injury (including illness and communicable disease) or property damage which I/Minor may have or which hereinafter may accrue to me/Minor against NCH from and against any liability arising out of or connected in any way with my/Minor’s participation in this Event, even though that liability may arise out of active or passive negligence or carelessness on the part of NCH. It is further understood and agreed that this waiver, release, and assumption of risks has been freely entered into and is to be binding on my/our heirs and assigns.

Additionally, I fully understand that that my/Minor’s participation in the Event exposes me/Minor to the risk of personal injury, death, communicable diseases, illnesses, viruses, and/or property damage. Knowing the risks, nevertheless, I hereby acknowledge that I/Minor am voluntarily participating in this activity and I agree to assume those risks on behalf of myself/Minor and to release and to hold harmless NCH who (through negligence or carelessness) might otherwise be liable to me/Minor (or my/our heirs or assignees) for damages.

Communicable Diseases:

I agree, understand, and acknowledge, on behalf of myself/Minor, that an inherent risk of exposure to communicable or infectious diseases,including, but not limited to, COVID-19 (as defined by the World Health Organization and any strains, variants, or mutations thereof) and SARS-CoV-2 (the virus that can cause COVID-19) (collectively, “COVID-19”), exists in any public place where people are present. “Communicable disease” means any disease or illness caused by microorganisms such as bacteria, viruses, parasites, or fungi that can be spread, directly or indirectly, from one person to another. “Infectious disease” means any disease or illness caused by microorganisms such as bacteria, viruses, parasites, or fungi that enter the body, multiply, and can cause an infection. For example, COVID-19 is an extremely contagious communicable disease that can lead to severe illness and death. No precautions can eliminate the risk of exposure to COVID-19, and the risk of exposure applies to everyone. According to the Centers for Disease Control and Prevention (“CDC”), older adults (people 65 years and older) and people of any age who have underlying medical conditions might be at higher risk for severe illness and death from COVID-19. I acknowledge that the risk of exposure to any communicable or infectious disease includes the risk of exposing others I/Minor later encounter, even if I/Minor am/are not experiencing or displaying any symptoms of illness.

I acknowledge and agree to voluntarily assume any and all risks in any way related to my/Minor’s exposure any and all other communicable or infectious disease, including illness, injury, or death of myself, Minor, or others, and including, without limitation, all risks based on the sole, joint, active or passive negligence of NCH. I acknowledge that my/Minor’s participation in the Event is entirely voluntary. By my/Minor’s participation in the Event, I attest I am knowledgeable about the individual risk of developing severe illness if I/Minor am/is infected with a communicable or infectious disease, including, but not limited to, COVID-19; I have made an informed decision about my/Minor’s participation in the Event based on my/Minor’s individual risk; and have decided whether to consult with a health care provider based on such individual risk. I further acknowledge and agree that I/Minor will follow all health and safety protocols issued by NCH or any health authority during the time of the Event.

WITH MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS RELEASE, WAIVER AND HOLD HARMLESS AGREEMENT AND FULLY UNDERSTAND AND AGREE WITH ITS CONTENTS, INCLUDING THE INFORMED CONSENT ABOUT COMMUNICABLE DISEASES. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND NCH AND I SIGN IT OF MY FREE WILL.

Enter full name of Parent, Guardian or Patient (over 18 years of age) filling out this form to serve as a digital signature:*