This is a legally binding Consent Form and Release of Liability made voluntarily by me, the undersigned Releaser, on my own behalf, and on the behalf of my heirs, executors, administrators, legal representatives and assigns to SENSE ABLE BRAIN. By the execution of this waiver of liability form, I acknowledge that the child listed above is/are capable of participating in the activities.  I also assume all risks of the student participating in the activities, whether such risks are known or unknown to me at this time.  I release and hold harmless this organization, leaders, employees, contractors, volunteers, and any agents from any claim the student or I may have due to the result of any injury or illness incurred during participation in the Sense Able Brain activities.  I accept and assume full responsibility for any and all injuries, damages, and losses that may occur to the student from any participation in the activities. In an emergency, I acknowledge that I am solely responsible for all medical and other costs arising out of bodily injury or any loss sustained through participation in this activity.  I authorize program/office/facility staff to secure any licensed hospital, physician, and/or medical personnel for any treatment deemed necessary for the participant's immediate care.

I hereby grant Sense Able Brain Therapy & Learning the irrevocable right and permission to use photographs and/or video recordings of my child(ren) on their website and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.  I understand and agree that such photographs and/or video recordings of my child(ren) may be placed on the Internet.  I also understand and agree that my child(ren) may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of them.  I waive the right to approve the final product.  I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Sense Able Brain.   I hereby release, acquit and forever discharge Sense Able Brain, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.  

Financial responsibility for services obtained at Sense Able Brain rests with you, the parent or guardian of the above named child, regardless of insurance or other treatment coverage plans.  We will provide a receipt for you to submit to the Gardiner Scholarship for reimbursement.  We can provide you with a Superbill upon request, and it is your responsibility, should you choose to seek reimbursement, to submit this claim to your insurance company or coverage plan.  The insurance company or other coverage plan will determine eligibility, necessity, and reimbursement rate.  We encourage you to check with your insurance company for extent of coverage in your plan before treatment begins if you plan to submit claims for reimbursement.

By typing your name in this box, you certify that you are authorized to make decisions for the above named child, that you agree to the liability releases as written, and that you agree to assume Financial Responsibility for services provided by Sense Able Brain Therapy and Learning Services.