Consent Form Release From Liability And Indemnity printable pdf download

CONSENT FORM, RELEASE FROM LIABILITY & INDEMNITY AGREEMENT

I/We, the undersigned parent(s) or guardian(s) of_________________________ , a minor, do

hereby CONSENT to his/her participation in the Newton Community Farm’s High School

Intern (hereafter referred to as the “Intern”) program for the weeks of

___

_____________, 20_____. I/We RELEASE and discharge the Newton Community Farm,

Inc., the City of Newton and its departments, officers, employees, and agents (hereinafter

collectively referred to as "Newton"), from any and all claims, damages, losses or expenses

of whatever kind or nature which I/we may have or acquire as the parent(s) or guardian(s) of

said minor arising out of or resulting, directly or indirectly, from said minor's participation in

the Intern program. I/We also RELEASE and discharge Newton from any and all claims,

damages, losses or expenses of whatever kind or nature which said minor may have or

acquire arising out of or resulting from, directly or indirectly, his/her participation in the

Intern program. I/We furthermore agree to defend and INDEMNIFY Newton against any

claim, damage, loss or expense of whatever kind or nature that Newton may have to pay that

arises from said minor's intentional, grossly negligent, or reckless acts or omissions while

participating in the Intern program.

I/We hereby authorize Newton's employee(s) or agent(s) who is supervising said minor to act

on our behalf in authorizing and consenting to emergency medical care for said minor if

he/she becomes ill or is injured while participating in the Intern program. This Authorization

and Consent may be presented to the appropriate emergency medical staff at such time as

emergency medical care is required. I/We hereby RELEASE and discharge Newton

Community Farm and Newton from any and all claims of any nature whatsoever, which may

arise out of the decision to provide emergency medical care.

_______________________________________________________________________

Signature of Parent or Guardian Date Relationship

_______________________________________________________________________

Signature of Parent or Guardian Date Relationship

THIS FORM MAY NOT BE ALTERED

Revised: 3/13/13

Greg Maslowe, Farm Manager

Newton Community Farm

617-916-9655

Consent Form Release From Liability And Indemnity