I, parent/guardian, hereby give permission for my child to participate in therapy services or events at Northwest Pediatric Therapy.

I understand that it is my responsibility to carry my own accident and medical insurance. In the event of an injury or accident, I authorize customary medical treatment if it becomes necessary, and transportation and emergency medical services, if warranted.

To the best of my knowledge, my child is capable of participating in motor activities and has had a physical in the last (12) twelve months. Any activity involving motion, jumping, rolling, running, etc. involves the possibility of serious, permanent or fatal injury. I understand the risks of participating in motor activities and using therapy/gym equipment. Therefore, in consideration for allowing my child to use the equipment and facility, I hereby forever release Northwest Pediatric Therapy and members of Northwest Pediatric Therapy (including, but not limited to, Northwest Pediatric Speech Therapy, and Sprout Pediatric Therapy, from all liability for any and all damages and injuries suffered by my child while under the instruction, supervision or control of Northwest Pediatric Therapy owners and therapists. This acknowledgement of risk and waiver of liability, having been read thoroughly and understood completely is signed voluntarily as to its content and intent.