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Participant Waiver and Release of Liability for Love Serving Autism, Inc. BY PARENT(S) OR LEGAL GUARDIAN(S) OF MINOR CHILD

Each of the undersigned parent(s) or legal guardian(s) of the adult named below states as follows:

I am aware that normal and usual athletic and sports related activities have certain inherent risks and may cause injury to participants. However, I want the child to participate in the Love Serving Autism, Inc., sponsored tennis program and other events (the "Activities"), and I give my unqualified permission and consent for the adult to participate in the Activities, subject only to any specific limitations noted below.

My child has the necessary skills and is able to participate in all reasonably anticipated aspects of the Activities except as noted below. The nature of the Activities has already been fully disclosed to me, and any brochure, flyer or announcement relating to the Activities is expressly made a part of this Authorization & Waiver.

I, on behalf of the adult, hereby indemnify, release, hold harmless and forever discharge the Organization and its agents, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I or my child ever had or may have, arising from or in any way related to my child's participation in any Activities conducted by, on the premises of, or for the benefit of nonprofit or for profit entities including Love Serving Autism Inc.; provided, that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct.

This Authorization & Waiver is binding upon me, my heirs, executors, legal representatives, successors and assigns. The provisions of this Authorization &Waiver will continue in full force and effect even after the termination of the Activities conducted by, on the premises of, or for the benefit of nonprofit or for profit entities including Love Serving Autism, Inc., whether by agreement, by operation of law, or otherwise.

This Authorization &Waiver is governed by the laws of the State of Florida and is intended to be as broad and inclusive as is permitted by that law. If any provision of this Authorization & Waiver is held invalid or unenforceable by a court of competent jurisdiction, the remaining provisions will continue to be fully effective.

This Authorization & Waiver contains the entire agreement between the parties, and supersedes any prior written or oral agreements between them concerning the subject matter of this Authorization & Waiver. The provisions of this Authorization & Waiver may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of all parties.

Any claim or controversy that arises out of or relates to this Authorization &Waiver or the alleged breach of it, and which cannot be settled by the parties, will be settled by submission to the chapter of the American Arbitration Association or similar group nearest to the Organization in accordance with its current rules and procedures.

In the event I cannot be reached, I authorize and direct any adult Activities sponsor or group leader representing Love Serving Autism, Inc., to make emergency medical decisions for the adult.

Medical Conditions. The Adult is subject to the following allergies or medical conditions, and I authorize the Organization to disclose such allergies or medical conditions to a physician in the event my child should require emergency medical care (describe allergies or medical conditions with specificity):

Prohibited Activities. As a result of the medical conditions described above or for other reasons, I do not want the adult to engage in any of the following activities (describe with specificity):

I am of lawful age and legally competent to sign this Authorization & Waiver. I understand the terms of this Authorization & Waiver and I have willingly signed it as my own free act.

Name and Address of Parent(s) or Guardian(s):

Photograph, Film or Vocal Recording Release for Love Serving Autism, Inc.

Love Serving Autism, Inc. may take pictures/video of the children participating in the program.
Note: I authorize this release based on the following conditions:

These records become the property of Love Serving Autism, Inc. or its representatives
This release is given without promise of compensation
This release is effective until terminated by a retraction in writing from the person granting this authorization
The parent/legal guardian and the patient do release to Love Serving Autism, Inc. any right, title and/or interest of any kind they may have in the records produced

I hereby grant to Love Serving Autism, Inc. the right and authority to photograph, film and/or record vocally:

These records may be used for promotional, publicity or teaching purposes and may be published in mass media publications, on the intranet or Internet sites, or shown on television or movie presentations.

The participant’s and family’s name may be used. This release is effective until revoked in writing by the undersigned. Such revocation shall only be effective to prevent any expanded future use of the records.

Research Consent: Communication Skills

Each of the undersigned parent(s) or legal guardian(s) of the adult named below states as follows:

1. It is important for future funding, that we document the communication success (receptive, expressive, social language skills) of the students during and upon exiting the program. Therefore, each student is being asked to agree to participate in various short-term and longitudinal studies. Information will be gathered, monitored, and documented during each participant’s time playing in the Love Serving Autism tennis program.

2. By signing this document, the applicants and their families acknowledge the fact that he/ she will be part of an on-going research project for the enhancement of adult’s language skills during tennis and agree that if they are selected for the program that they are willing to participate in the research.

Health History Form & Medical Waiver

Birth Date

Gender MaleFemaile

Does child have any of the following illnesses? If yes please explain below

Heart disease / defect

High or low blood pressure problem

Asthma / lung disease

Epilepsy / Seizure disorder

Diabetes / low blood sugar

Fainting / dizziness disorder

Musculoskeletal disorder

Eye / Ear disorder (besides corrective lenses)

Digestive / urinary problems

Allergies (food, insects, medicine, etc)

pmental disorder

Any other health disorder not mentioned above

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Your legal name

Please Confirm full name and signature.

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Signed by Lisa Pugliese
Signed On: January 8, 2018

Timestamp

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March 6, 2017 1:15 pm EDT

Participant Waiver and Release of Liability for Love Serving Autism, Inc. BY PARENT(S) OR LEGAL GUARDIAN(S) OF MINOR CHILD Uploaded by Lisa Pugliese - info@loveservingautism.org IP 73.137.165.85