I, the undersigned, on behalf of my minor child and myself, hereby represent and agree as follows:
I certify that I am the parent or legal guardian of the minor child (named above) and that I have the right to make decisions for my child that affect his/her/their wellbeing. I understand that my child will be a participant in the Group and I hereby give permission for my child to participate.
I understand that the Group will include discussion of healthcare, school, social and family issues and the management of chronic pain and that the level of my minor child’s participation in the Group and any Group activities must be determined by me, in consultation with my minor/child’s physician or other qualified healthcare provider.

I further understand that the Group leaders are volunteers and people with pain who have undergone training with U.S Pain Foundation, Inc. and that they are not physicians, psychiatrists, psychologists or other trained medical practitioners. U.S. Pain Foundation, Inc. is dedicated to serving those who live with pain conditions and their care providers but does not advocate any one particular treatment for any one type of pain.

I acknowledge that the Group leaders and/or U.S. Pain Foundation, Inc., by making this group available, are not undertaking any responsibility regarding my minor child’s medical condition(s). If I feel that his/her/their medical condition(s) are adversely affected by participation in the Group, l understand that it is my responsibility to discontinue my minor child’s participation and to immediately consult with his/her/their healthcare provider about continuing or resuming participation.

I agree that all information obtained in the support group is to be considered confidential and I shall hold the same in confidence, shall not disclose, publish or otherwise reveal any of the confidential information received from my minor child and/or any participants in the Group and/or U.S. Pain Foundation, Inc. to any other party whatsoever.

I hereby, on behalf of my minor child, myself, our heirs, executors, administrators, and assigns, assume the risks associated with my minor child’s participation in the Group and release, indemnify and hold harmless the group leaders, U.S. Pain Foundation, Inc. and it’s agents, officers, members, volunteers and employees from any and all claims, demands, for personal injuries, costs, expenses, and any other loss to person or property that I or my minor child may suffer or have which arise out of or result from my minor child’s participation in the Group.

I have read this parental consent and waiver of liability, I have been given the opportunity to ask any questions, and I fully understand and agree to the above.