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Parent/Guardian Health & Transition from Vehicle to Session

Form

 

I ________________________________, the parent of __________________________ (“my child”),

 

Understand that personal injury can and may occur to my child, and I hereby authorize Social Scholars Licensed Educational Psychology Inc., to seek and consent to emergency medical attention for my child as needed; and I further agree to be liable for and to pay all costs incurred in connection with such medical attention. 

 

I hereby release Social Scholars Licensed Educational Psychology Inc, its providers/therapists, and other staff from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in or traveling to his/her therapy/session.

 

I agree and consent to all the above statements.

 

(Parent Signature)                                                    (Date)

_____________________________________________________________________________

(Emergency Contact Name and Phone Number)

       

 

                                                    

16200 Ventura Blvd, Encino, CA

 (818) 208-9874

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