IncluCity Delegate Application

I acknowledge Inclusive Communities has put in place preventative measures to reduce the spread of COVID-19 and that Inclusive Communities cannot guarantee that my child/the child in my care will not become exposed to or infected with the COVID-19. By checking this box I also acknowledge that eligibility for this program is contingent on my ability to follow the precautions mandated by Inclusive Communities knowing that these are subject to change to protect all participants of the program.

Additionally, I acknowledge the contagious nature of COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I acknowledge that Inclusive Communities cannot guarantee that my child/the child in my care will not become exposed to or infected with the COVID-19.

I understand that the risk of becoming exposed to and/or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Inclusive Communities staff, program participants and their families.

I acknowledge that my child/the child in my care/or I, is/are voluntarily participating in programming provided by Inclusive Communities and acknowledge that this increases my child’s/the child in my care’s risk to exposure to COVID-19. I acknowledge that my child/the child in my care and I must comply with all set procedures to reduce the spread while attending Inclusive Communities programming.

I hereby release and agree to hold Inclusive Communities harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act by Inclusive Communities, or that may otherwise arise in any way in connection with any services received from Inclusive Communities. I understand that this release discharges Inclusive Communities from any liability or claim that I, my heirs, or any personal representatives may have against Inclusive Communities with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Inclusive Communities. This liability waiver and release extends to Inclusive Communities together with all owners, partners, employees, and program volunteers.

Parent /Guardian must sign the emergency release agreement, unless the applicant is over 19 years of age. In the event of an accident or illness which requires emergency medical care, I hereby give my permission to the attending (licensed) nurse/medical technician and/or physician to order such medical attention as may be deemed necessary for the health and safety of myself (or my child of whom I am the legal guardian). In the event of an accident or illness which requires emergency medical care, I hereby give my permission to the attending (licensed) nurse/medical technician and/or physician to order such medical attention as may be deemed necessary for the health and safety of myself (or my child of whom I am the legal guardian of). In the event that I cannot be reached in an emergency, I hereby give permission to the physician at the institution selected by the Inclusive Communities staff member to secure and administer treatment, including hospitalization, for the person named above. I have provided a phone number and other pertinent information on this form so that the Inclusive Communities staff may notify me in case of emergency. The medical information provided above is complete and accurate to the best of my knowledge. I take responsibility to update this information to ensure Inclusive Communities will always have updated information on me (or my child).