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SA Buddy Registration
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Buddy / Volunteer Information
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Parent / Guardian Information
Parent or Guardian Name
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Consent Forms
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by West Texas Rehab Center during the selected camp. In exchange for the acceptance of said child’s candidacy by West Texas Rehab Center . I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless West Texas Rehab Center and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against West Texas Rehab Center . including all affiliates, all participants and, if applicable, owners and lessors of premises used to conduct the event.
*
Yes
No
West give “Materials”)
I hereby grant to West Texas Rehabilitation Center, their agents, successors, assignees, and affiliates, and their respective employees, officers, directors, board members, and representatives (collectively “Producers”) the right and permission to film, photograph, and record me, transcribe the recording, and to use my name, voice, image, information about me and any ideas or materials that I provide Producers (collectively, the “Materials”) in works created by Producers (the “Program”) and in connection with advertising, publicizing, broadcasting, producing, and exploiting the Program, in any and all media and mediums now known hereafter developed, in perpetuity. I understand that Producers are under no obligation to incorporate my appearance in the Program. Producer may edit and Video as it sees fit, and may resnlate the Material into languages other than English.
*
Yes
No
Signature
*
Clear Signature
If not 18+ a parent or guardian must sign.
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