Special Needs Child Information Form

If yes, please answer the questions below) 

antecedents of behaviors

behaviors

consequences of behaviors

current behavior strategies/supports. 

For example, first/then, positive reinforcement, negative reinforcement, picture schedules, etc.

DEFINITIONS: • The term “MINOR” shall collectively be referred to the Minors referenced above. • The term “ACTIVITY” shall refer to the event and activity referenced above. • The term “CLAIMS” shall refer to any and all liability, claims, demands, debts, causes of action, suits, judgments, costs, losses, expenses, attorney’s fees, and any other obligations. • The term “CHURCH OF SOUTHLAND” shall refer to its directors, officers, affiliates, successors, predecessors, parents, subsidiaries, pastors, principals, shareholders, interns, employees, volunteers, teachers, staff members, drivers, administrators, security guards, agents, members, and any other representatives. INFORMED CONSENT: I, the undersigned, am the parent and/or legal guardian of the MINOR and hereby understand the various aspects of the ACTIVITY. I understand that the MINOR could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only the CHURCH OF SOUTHLAND’s actions, inaction, or negligence but also the action, inactions, or negligence of others, conditions of equipment used, and that there may be other risks not known or not reasonably foreseeable at this time. I further understand and agree that any injury, illness, property damage, disability, or death that the MINOR may sustain by any means is my sole responsibility. I consent that the MINOR is permitted to receive medical treatment which may be deemed advisable and reasonable in the event of injury, accident, and/or or illness during the ACITIVTY. ASSUMPTION OF RISK: I, the undersigned, am the parent and/or legal guardian of the MINOR and hereby request that the MINOR be permitted to participate in the ACTIVITY. I understand that participation in the ACTIVITY presents certain inherent risk of injury to the Minor that cannot be eliminated regardless of care taken. The ACTIVITY may involve various activities such as physical exercise, sporting activities, travel, consumption of food, weather conditions, negligent or willful acts, supervision, and first aid treatment. I certify that the MINOR is physically and mentally fit to participate in the ACTIVITY. In exchange for the MINOR’s participation, I knowingly and voluntarily agree to fully assume any and all risks for injuries whatsoever whether known or unknown arising out of, or related to, the MINOR’s participation in the ACTIVITY. RELEASE AND WAVIER OF LIABILITY: As a condition of the MINOR’s participation in the ACTIVITY, I, on behalf of myself and my representatives, heirs, executors, trustees, administrators, agents and assigns hereby will and do release, waive, discharge, and covenant not to sue the CHURCH OF SOUTHLAND for any and all CLAIMS of any kind whatsoever whether known or unknown arising out of, or related to, any injuries, property damages, and death as a result of directly or indirectly participating in the ACTIVITY even if the CLAIMS are caused by the negligence of the CHURCH OF SOUTHLAND. I understand that the MINOR may be photographed, videotaped, or otherwise recorded during the ACTIVITY. I fully authorize the use of these photos, images, videos, sound or other recordings, including the MINOR’s likeness, in promotional materials by the CHURCH OF SOUTHLAND. I understand that neither the MINOR nor the undersigned parent/guardian will receive any royalties or compensation for the use of these materials. INDEMNITY: As a condition of the MINOR’s participation in the ACTIVITY, I, on behalf of myself and my representatives, heirs, executors, trustees, administrators, agents and assigns agree to hold harmless, defend and indemnify the CHURCH OF SOUTHLAND for any and all CLAIMS of any kind whatsoever whether known or unknown arising out of, or related to, any injuries, property damages, and death as a result of directly or indirectly participating in the ACTIVITY even if the CLAIMS are caused by the negligence of the CHURCH OF SOUTHLAND. CHOICE OF LAW & SEVERABILITY: I hereby agree that this waiver and release shall be construed in accordance with the laws of the State of California and that this waiver and release is intended to be as broad and inclusive as permitted by such law. I further agree that if any portion herein is held invalid, the balance shall, notwithstanding, continue in full force and effect. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF ABILITY AND A CONTRACT AND I SIGN IT ON MY OWN FREE WILL.