The teacher, Heiny Gutierrez, is deeply committed to every child’s safety and carefully assesses and manages danger in all of our activities. However, there are risks inherent in any youth activity. Each family must submit this completed form in order to participate.

Acknowledgement of Risk and Consent for Treatment: I acknowledge that there are risks inherent in any youth program, including but not limited to injury arising from: participation in physical activity; participant’s failure to follow instructions given by the teacher; communicable illness; and independent acts of third parties not under the control of the teacher. I acknowledge that all risks cannot be prevented, and assume those beyond the control of the teacher. In order to minimize risks to my child or other participants, I will take responsibility to see that my child is prepared for all activities and is in good health each day of class. In case of medical emergency, I understand that every reasonable attempt will be made to contact me. However, in the event that I cannot be reached, I give my permission to the teacher in charge of the class to secure emergency medical treatment for my child. I agree to pay for any charges for emergency medical treatment that are not covered by my personal health insurance.