I consent to receive, or if participant is under 18, for my child to receive, emergency medical treatment in case of injury or illness. The information provided is accurate to the best of my knowledge.

I, the undersigned, hereby consent to participate or allow my child’s participation in a medical learning experience at DRH Health, as sponsored by the EHCO Program.

I understand and acknowledge that participation in activities taking place in a health care environment involves inherent risks and hazards, including the risk of exposure to disease and blood/body fluids, and other potential risks. Although I understand that these risks may have serious consequences, on behalf of myself or my child, I hereby expressly assume all of these risks, known or unknown, which could occur through my participation or my child’s participation in the Program, and, on behalf of myself or my child and, I assume personal responsibility for my health or my child’s health and safety while I or my child participates in the Program. In addition, I understand that I am responsible for expenses incurred for any medical or health care services (emergency or otherwise) I or my child may require as a result of participating in the Program.

As an inducement for and in consideration of my or my child’s participation in the Program, on behalf of myself or my child, I hereby agree that DRH Health, its subsidiaries and affiliated corporations and their respective directors, officers, employees and agents, will not be liable for any personal injuries, medical claims, damages or other expenses which may occur from my or my child’s participation in the Program. On behalf of myself or my child, I hereby release DRH Health, its subsidiaries and affiliated corporations and their respective directors, officers, employees and agents, from any and all claims or demands which I or my child may now have or have in the future which result from my or my child’s participation in the Program, and, on behalf of myself or my child, I agree not to sue DRH Health, its subsidiaries and affiliated corporations and their respective directors, officers, employees and agents, for any such claims or demands.
This Release is intended to be as broad and inclusive as permitted by law, and if any portion of this document is found to be invalid, the rest of this document will remain in effect. This Release shall be binding on my heirs, executors, administrators and assigns.

I do hereby authorize DRH HEALTH and the DRH HEALTH FOUNDATION to copyright, publish, and use (in all forms and media, and all manners for advertising trade, promotion, exhibition, or any other lawful purpose whatsoever) still, single, multiple or moving photographic or video portraits of me in which I may be included in whole or in part, or composite or distorted in character or form, in conjunction with my own or fictitious name, or reproductions thereof in color or otherwise for other derivative works made through any medium.

I do hereby waive any right I may have to inspect and/or approve the finished product or advertising copy that may be used in connection therewith, or the use to which it may be applied. I release DRH Health, the DRH Health Foundation and any other related representative from any liability whatsoever arising, or alleged to arise, by virtue of any form of aural, optical, compositional, or composite distortion that may occur while taking, processing, composing, editing, reproducing, publishing, or displaying said media. I further grant DRH Health and the DRH Health Foundation with the sole rights to any performance contained in said media.

I am the person named below and have legal authority to execute the above release. I approve the foregoing and waive any rights in the premises.