The health information provided is correct and complete to the best of my knowledge and belief. As parent/legal guardian, I hereby give permission for the child(ren) named herein to engage in all program activities. I hereby give permission to Noggin Builders, LLC to provide emergency care and seek emergency medical, surgical, or dental treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for payment, treatment, or insurance purposes. In the event of an emergency, I give permission to Noggin Builders, LLC to arrange necessary related transportation for the child(ren) named herein. In the event that I cannot be reached in an emergency, I hereby give permission to the physician/health care provider selected by Noggin Builders, LLC to secure and administer treatment, including hospitalization, for the child(ren) named herein. This completed form may be photocopied, if needed. I understand that the child(ren) named herein will be participating in programs and activities at Noggin Builders, LLC. I acknowledge that such programs and activities involve inherent risks. I hereby waive, release and forever discharge and indemnify Noggin Builders, LLC and its employees, members, managers, officers, agents, insurers and representatives from any and all claims, damages and causes of action, including attorney's fees, as a result of the participation by the child(ren) named herein in any activities at or associated with Noggin Builders, LLC. I give my permission to Noggin Builders, LLC to use any video or photograph that includes the likeness of the child(ren) named herein, in any form or media, for the purpose of marketing or promoting Noggin Builders, LLC and its programs.
