Release for Child’s Participation

(Guardian’s name) give permission for my child (Child’s name) to participate in the Children’s Program at Cancer Support Community Valley Ventura Santa Barbara (CSC VVSB).

• I understand that my child will be exposed to age-appropriate medical terminology, including the words, “cancer, “chemo”, and “radiation”.
• I understand that my child will be learning social and emotional concepts and coping skills related to such stress, anger, sadness, isolation and grief.
• I understand that I should refrain from bringing my child to CSC VVSB if they are sick.
• I understand that though CSC VVSB provides structured play and social activities, its purpose is centered on educating and supporting children whose lives have been touched by cancer through support and expressive play activities.
• I understand the importance of notifying staff of any significant changes in my child’s life.
• I understand that if necessary, staff may request a family meeting to discuss my child’s needs as well as their appropriateness for the program.
• I understand that while my child is in an activity, I (or my designated substitute) am to remain in the building unless otherwise specified.

ON PRIVACY: I have been advised that at CSC VVSB, confidentiality is promised to children, except in situations where they or another person might be endangered. I understand that while CSC VVSB encourages respect for privacy CSC VVSB has control only over staff and volunteers. CSC VVSB can not guarantee confidentiality between members.

CHILD’S PARTICIPATION IN ACTIVITIES:
I understand and agree that:
• Participation in any activities at CSC VVSB is entirely voluntary and is not a required condition of my child’s membership.
• I have been advised to consult my child’s physician, or other healthcare professional, before having him/her participate in any physical activities and to follow his/her physician’s, or other healthcare professional’s advice with respect to such activities;
• Any recreational or physical activity involves some risk of injury, whether apparent or not, and by participating in any such activity I assume all risks for my child, known or unknown, whether foreseeable or not:
• In consideration of CSC VVSB’s assent to the use of its premises and/or facilities for non-employment related recreational and physical activities, I release CSC VVSB of any and all liability for any injury or damages resulting from or incurred in connection with my child’s participation in any recreational and/or physical program except to the extent that such injury or damages are caused by gross negligence on the part of CSC VVSB, and I agree to indemnify and hold CSC VVSB harmless with respect to any claim rising from any intentional or negligent conduct on my child’s part.