This is a copy of the Program Waiver and Release of Liability Agreement to which you have agreed today.   Print a copy of this Agreement.

___ I have read and agree to the terms and conditions below: 

Name of Child (hereinafter “my CHILD”): _______________________________________

I, the parent or guardian of my CHILD, give permission for my CHILD to attend the Staten Island Children’s Museum (hereinafter, SICM) Summer Camp program. The program activities may include but not be limited to running/ walking/ hiking, dance, theater games, art, science activities, playing outside, and gardening.

Medical Treatment

If my CHILD is injured and requires medical attention, I give consent and authority to SICM to obtain emergency medical treatment on my CHILD’s behalf and do hereby release and forever discharge SICM from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the SICM camp activities.

Liability

I hereby release the SICM from any and all claims which I or my CHILD may have against the Program arising from, resulting from or in connection with the camp; including but without limitation, any claims, demands or causes of action for injuries to my CHILD, including but not limited to injuries resulting from the negligence of SICM. I understand SICM is not responsible for theft, loss or damage of personal property. The agreement is signed for the purpose of fully and completely releasing, discharging, and indemnifying SICM from all liability as herein described.

Photograph and Interview Release

In exchange for the opportunity for my CHILD to participate in the SICM Summer Camp program, I irrevocably authorize SICM and its affiliate, licensees, assignees, and successors to photograph or interview my CHILD and to use such photographs or interviews, as well as the name of my child in any of its promotional materials, including its brochures, advertisements, newspapers, web sites, videos, or other materials in print, audio, electronic or visual media.

In addition, I voluntarily waive any right, cause of action or demand, of any kin whatsoever resulting from SICM’s photograph or interview of my CHILD from which any liability may or could accrue to SICM.

I also understand that SICM will not give me or my CHILD any compensation for using my CHILD’s photograph or interview in its promotional materials. Thus, by signing this document, I waive any rights to any compensation now or in the future.

I understand that this document includes the entire agreement and understanding between me and SICM with respect to the release of photographs or interviews of my CHILD.

Parent or Legal Guardian

Signature:       _____________________________________________ Date: _______________

Name Printed: _____________________________________________