Complete this application for each of your children under the age of 18.

PLEASE READ CAREFULLY, AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.  I affirm that I have legal custody of the minor children/persons indicated below. Should an emergency occur during the duration of BREAKAWAY, I give my authorization and consent for the BREAKAWAY staff to authorize necessary medical care for this child. Such medical treatment shall be provided upon the advice of and supervision by any physician, surgeon, or other medical practitioner licensed to practice in the United States.  I give my consent that information on this application may be communicated to BREAKAWAY staff and Crew Members for the purpose of being equipped to provide the best care and assistance possible to my family.  Permission is given only to Lift Disability Network to use photographs (individual or group) and/or multi-media images and recordings in the best interest of Lift Disability Network. I understand that photographs/video/images I take at any BREAKAWAY/Lift Disability Network function are for my personal use only. Personal internet use of any video/media should be approached with caution with regard to misrepresentation.  I release Lift Disability Network, its staff, and Crew Members, and the BREAKAWAY facility from all actions, damages, or personal injuries which may occur to me or a member of my family. I understand in the event of a minor injury I, or a member of my family, may receive first aid treatment. I will be informed as soon as possible of any injury or condition of one of my family members and will be responsible thereafter for their care. In the event of an emergency, injury, or illness, emergency medical services and I will decide the best course of action. If the BREAKAWAY staff is unable to reach me, I authorize them to take whatever action is necessary for the safety and health of my family members.  I realize that tobacco, alcohol, and illegal drugs are NOT ALLOWED.