I authorize the following Parent/Guardian or Authorized Party to pick up my child from the Firehouse. I understand that if the persons named below are unable to pick up my child, I will provide a permission form to authorize another adult to pick up my child from the Firehouse.

~Parent/Guardian Information ~

Please provide at least one other adult authorized to pick up your child(ren) from Summer Pass.

List an individual we may contact and/or release your child to in an emergency other than individuals already listed above. (Optional)

The Kearney Enrichment Council has put in place preventative measures to reduce the spread of COVID-19; however, the organization cannot guarantee that you, participants, and/or your child(ren) will not become infected with COVID-19. Further, attending the Kearney Firehouse Community Center could increase your risk, participants and your child(ren)’s risk of contracting COVID-19.

By agreeing to this waiver, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that myself, participants, and child(ren) may be exposed to or infected by COVID-19 by attending the Kearney Firehouse Community Center and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Kearney Firehouse Community Center may result from the actions, omissions, or negligence of myself and others, including, but not limited to, contract staff, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren), participants or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I, fellow participants, child(ren) may experience or incur in connection with my attendance at the Kearney Firehouse Community Center. On my behalf, and on behalf of my participants, I hereby release, covenant not to sue, discharge, and hold harmless the Kearney Enrichment Council, its contract staff, the board of directors, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Kearney Enrichment Council, its contract staff, the board of directors, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any event held here.

By checking the box below, I hereby affirm that I have read and agree to the COVID-19 Agreement/Waiver outlined above.

Please sign and date below on behalf of the child listed above, evidencing as their parent/guardian, permission and consent of the following:
• Permission to participate in supervised field trips that will be scheduled during program sessions. Field trips will be on foot and in close proximity to the Firehouse Community Center.
• Permission for the Firehouse to photograph me, and/or my children and to use any images thus obtained in their various publications for the promotion of the Firehouse and its programs.
• I hereby acknowledge that the Firehouse is not responsible for any lost or stolen personal property.
• As parent/guardian, I hereby give Firehouse permission to seek medical attention for my child in case of accident or emergency. I understand that every effort will be made by Firehouse staff to contact me and/or the emergency contacts in the event of a medical emergency. In the event of an emergency, if you or your emergency contact(s) cannot be reached, KEC staff will call 911.
• I understand and agree that by obtaining certain medical information about my child, Firehouse Community Center is not undertaking any obligation with respect to my child’s medical condition or treatment.
• I understand and agree that if my child is injured or causes injury to others during or in connection with participation in any Firehouse program, I hereby release, indemnify and will hold harmless Kearney Enrichment Council, the Firehouse Community Center, its employees, agents, trustees, instructors, and volunteers from any and all claims arising out of any such injuries.