WFUBMC Parent-Tot Program
Application, Medical Information, Liability Release & Parental Consent Form
Name: ____________________________ Age: _____ Date of Birth _______________
Parent/Guardian Name: _______________________ Telephone: ____________________________
Address: ____________________________________________________________________________
Street City State Zip
In case of emergency, contact: ___________________ Relationship: __________ Phone ____________
Is child comfortable in the water? Yes___No___ Is parent comfortable in the water? Yes___No___
Does child have any water experience? Yes___ No ___ Can child float? On front _____ on back _____
Has child previously worn swimmies or life jacket for comfort in the water? Yes___ No __
Comments: ___________________________________________________________________________
Release of Liability/Parental Consent Form
I, _____________________________, hereby release, waive, discharge and covenant not to sue Wake Forest University Baptist Medical Center, North Carolina Baptist Hospitals, Inc. and Wake Forest University School of Medicine, their affiliates, agents, therapists, and other employees of the organization, other participants, sponsoring agencies, their heirs, successors and assigns, and if applicable, owners, and lessors and lessees of premises; all of which are hereinafter referred to as “releasees” from demands, losses or damages on account of injury, including death, or damage to property caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise.
I/ We have read the above waiver and release, understand that I/we have given up substantial rights by signing it, have not changed it orally, and sign it voluntarily.
___________________________________ ____________________________________
Participant’s Name Participant’s Signature
Please read and sign if participant is a minor or under the care of Person Authorized to Consent
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided in favor of the Releasees, and, for myself, my heirs, assigns, and next of kin. I release and agree for myself and my minor child to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in this program as provided above.
___________________________________________________________ ____________________
Signature of Parent or Person Authorized to Consent for Participant Date
Medical Information (if applicable):
Diagnosis/Past Medical History and Surgeries: _____________________________________________________
Medications: ________________________________________________________________________________
List special precautions (i.e. ear plugs required, feeding tubes, etc.) ____________________________________
___________________________________________________________________________________________
Seizure Occurrence? Y __ N __ If yes, when was the last seizure? __________________________________
How often do the seizures occur? _________________________ Date of last Tetanus Booster _______________
Does the child use any of the following assistive devices? W/C______ Walker _____Crutches____
Leg Braces ____ Artificial Limb ____Other______ When should device be worn? ____________________
If child has Down Syndrome, has he/she been x-rayed for Atlanto-axial instability? Y ____ N _____ N/A ____
Physician Information
Physician’s Name _________________________________ Physician’s Phone # _______________________
Physician’s Address _________________________________________________________________________