Shiva Robotics Academy
Informed Consent and Waiver Form
Acknowledgement of Risk:
I hereby acknowledge that I have voluntarily chosen to allow my child to attend Shiva Robotics Academy’s LEGO Robotics Class Event (the “Class”). The activities in which my child may participate at class may include, but are not limited to: games, LEGO activities, and outdoor activities.
I understand the risks involved in these activities. I recognize that each class activity involves risk of injury to my child and I agree to accept any and all risks associated with it. By voluntarily allowing my child to participate in class activities and with the knowledge of the risks involved, I hereby agree to accept any and all inherent risks.
Indemnity and Hold Harmless:
In consideration of allowing my child to participate in Shiva Robotics Academy’s Class and to the fullest extent permitted by law, I hereby indemnify, hold harmless, release, and discharge Shiva Robotics LLC, a Florida limited liability company, d.b.a. Shiva Robotics (“Shiva Robotics” or “Shiva Robotics Academy”), and its principals, officers, members, agents, successors, assigns, contractors, employees, volunteers and assigns from and against all claims, liability, demands, damages, rights of action or causes of action (collectively, “Claims”), present or future, arising out of or connected with my child’s participation in the Class, including any Claims related to injuries or property damage resulting from such use or activities.
THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF EQUIPMENT MALFUNCTION OR MISUSE, ANY SLIP OR FALL, AND ANY NEGLIGENT INSTRUCTION OR SUPERVISION.
Child Will Abide By Rules and Regulations:
I have instructed my child to cooperate and comply with all reasonable directions and instructions received from class staff. I have reviewed the Class Rules, Expectations, and Consequences outlined in the preparation package with my child. I understand that any violation of class rules will result in consequences, and ultimately dismissal from class. I understand that if my child is dismissed from the class, I will not receive a refund for any unused portion of the pre-paid class fee.
Commitment to Being Available:
I commit to being available during class hours to answer a phone call from Shiva Robotics Academy and its staff. I have provided a phone number to Shiva Robotics Academy where I can be reached at any time during class hours. I also commit to being available or making arrangements for my child to be picked up for any reason and at any time during class hours.
Consent to Administer Non-Emergency First Aid:
I understand and acknowledge that occasionally a non-emergency may develop which necessitates the administration of non-emergency First Aid to my child. Therefore, in the event of non-emergency injury or illness, which necessitates the administration of non- emergency First Aid, I hereby authorize Shiva Robotics Academy and its staff in charge of the Shiva Robotics Academy’s Class to administer any necessary non-emergency First Aid. Non-emergency First Aid treatment may include but is not limited to: cleaning, applying antibiotic ointment to, and bandaging cuts or abrasions; removal of ticks and splinters; and applying an ice pack to bites, stings, or an injury. The following substances may be used in the administration of non-emergency First Aid: water, ice pack, ACE bandage, antibacterial soap, alcohol swabs, antibiotic ointment, and Band-Aids. No oral medication will be administered unless authorized and directed by the child’s parent/guardian.
I understand that if I do not consent to the administration of non-emergency First Aid or to the administration of any of the substances listed above, I will give written notification to Shiva Robotics Academy no later than seven business days before the class begins.
Consent to Administer Emergency First Aid:
In the unlikely event of a life- or limb-threatening emergency, I give consent to Shiva Robotics Academy and its staff to administer emergency First Aid as a first response until more advanced medical care is available. I understand that Shiva Robotics Academy and its staff will use their best judgment, act in good faith, and will treat with the intention of not causing further harm.
Consent to Arrange Emergency Treatment:
I understand and acknowledge that on rare occasions an emergency may develop which necessitates the administration of medical care, dental care, hospitalization, or surgery to my child. Therefore, in event of injury or illness to my child, which necessitates emergency medical or dental care, I hereby authorize Shiva Robotics Academy and its staff in charge of the Shiva Robotics Academy Class to arrange any necessary emergency treatment including the administration of anesthetics and surgery to my child. I also understand that a parent/guardian will be contacted at the earliest possible moment in the event of an emergency relating to my child.
Medical, Dental, Health, and Insurance Responsibilities:
I understand and acknowledge that Shiva Robotics Academy cannot assume responsibility for determining the medical, dental, or health condition of my child. Therefore, I have consulted with a medical doctor and/or dentist, as I have deemed necessary, with regards to my child’s individual medical or dental issues or needs, and find my child physically and mentally fit to participate in the Shiva Robotics Academy’s Class. If my child is required to receive medical, dental, or hospital services during class, I am aware that Shiva Robotics Academy cannot and does not assume legal responsibility for payment of such costs; rather, I hereby assure Shiva Robotics Academy that I have assumed all risk and responsibility thereof and that my child has the necessary insurance to meet any and all needs for payment of these services during the Shiva Robotics Academy Class.
Permission to Use Photograph or Likeness:I understand that Shiva Robotics Academy offers school pictures two times a year, in the spring and fall. I further understand that I am under no obligation to purchase the photos that are taken of my child or pictures that my child may be in.
I also understand that Shiva Robotics Academy may take pictures of the children playing from time to time for use with a project or for production of promotional materials for Shiva Robotics Academy, its affiliates, and any of its partner organizations. I understand that pictures are sometimes used to help show parents what their children are doing during the day. I realize that photos may be displayed in the room from time to time and could possibly include my child. I also realize that my child might be in the background or play area with another child when a picture is taken and that it is possible that that particular picture might be sent home with the other child to show their parents what they are doing.
I agree to give permission for Shiva Robotics Academy to take photographs or video images of my child. I agree to allow these photographs to be displayed in my child’s classroom, on other classroom or center bulletin boards, or on Shiva Robotics Academy and our affiliate/partner organization social media/websites/Youtube Channel or to be used as mentioned above. I further agree to allow the center to use these photographs or video images in promotional or training applications.
I hereby give my permission to Shiva Robotics Academy to use my child’s photographic image, in whole or in part, for camp-specific public information and for marketing activities at the discretion of Shiva Robotics Academy. I understand that the photography remains the property of Shiva Robotics Academy.
□ Check this box if you do NOT give the above permission to use your child’s photograph or likeness.
I HAVE CAREFULLY READ THIS AGREEMENT AND I FULLY UNDERSTAND ITS CONTENTS AND SUBMIT IT OF MY OWN FREE WILL. I AGREE TO THE TERMS OF THIS AGREEMENT AND UNDERSTAND THAT IT CANNOT BE MODIFIED ORALLY.
NOTICE TO THE MINOR CHILD'S NATURAL GUARDIAN
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF SHIVA ROBOTICS LLC USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO RECOVER FROM SHIVA ROBOTICS LLC IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND SHIVA ROBOTICS LLC HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
Informed Consent and Waiver Form
Acknowledgement of Risk:
I hereby acknowledge that I have voluntarily chosen to allow my child to attend Shiva Robotics Academy’s LEGO Robotics Class Event (the “Class”). The activities in which my child may participate at class may include, but are not limited to: games, LEGO activities, and outdoor activities.
I understand the risks involved in these activities. I recognize that each class activity involves risk of injury to my child and I agree to accept any and all risks associated with it. By voluntarily allowing my child to participate in class activities and with the knowledge of the risks involved, I hereby agree to accept any and all inherent risks.
Indemnity and Hold Harmless:
In consideration of allowing my child to participate in Shiva Robotics Academy’s Class and to the fullest extent permitted by law, I hereby indemnify, hold harmless, release, and discharge Shiva Robotics LLC, a Florida limited liability company, d.b.a. Shiva Robotics (“Shiva Robotics” or “Shiva Robotics Academy”), and its principals, officers, members, agents, successors, assigns, contractors, employees, volunteers and assigns from and against all claims, liability, demands, damages, rights of action or causes of action (collectively, “Claims”), present or future, arising out of or connected with my child’s participation in the Class, including any Claims related to injuries or property damage resulting from such use or activities.
THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF EQUIPMENT MALFUNCTION OR MISUSE, ANY SLIP OR FALL, AND ANY NEGLIGENT INSTRUCTION OR SUPERVISION.
Child Will Abide By Rules and Regulations:
I have instructed my child to cooperate and comply with all reasonable directions and instructions received from class staff. I have reviewed the Class Rules, Expectations, and Consequences outlined in the preparation package with my child. I understand that any violation of class rules will result in consequences, and ultimately dismissal from class. I understand that if my child is dismissed from the class, I will not receive a refund for any unused portion of the pre-paid class fee.
Commitment to Being Available:
I commit to being available during class hours to answer a phone call from Shiva Robotics Academy and its staff. I have provided a phone number to Shiva Robotics Academy where I can be reached at any time during class hours. I also commit to being available or making arrangements for my child to be picked up for any reason and at any time during class hours.
Consent to Administer Non-Emergency First Aid:
I understand and acknowledge that occasionally a non-emergency may develop which necessitates the administration of non-emergency First Aid to my child. Therefore, in the event of non-emergency injury or illness, which necessitates the administration of non- emergency First Aid, I hereby authorize Shiva Robotics Academy and its staff in charge of the Shiva Robotics Academy’s Class to administer any necessary non-emergency First Aid. Non-emergency First Aid treatment may include but is not limited to: cleaning, applying antibiotic ointment to, and bandaging cuts or abrasions; removal of ticks and splinters; and applying an ice pack to bites, stings, or an injury. The following substances may be used in the administration of non-emergency First Aid: water, ice pack, ACE bandage, antibacterial soap, alcohol swabs, antibiotic ointment, and Band-Aids. No oral medication will be administered unless authorized and directed by the child’s parent/guardian.
I understand that if I do not consent to the administration of non-emergency First Aid or to the administration of any of the substances listed above, I will give written notification to Shiva Robotics Academy no later than seven business days before the class begins.
Consent to Administer Emergency First Aid:
In the unlikely event of a life- or limb-threatening emergency, I give consent to Shiva Robotics Academy and its staff to administer emergency First Aid as a first response until more advanced medical care is available. I understand that Shiva Robotics Academy and its staff will use their best judgment, act in good faith, and will treat with the intention of not causing further harm.
Consent to Arrange Emergency Treatment:
I understand and acknowledge that on rare occasions an emergency may develop which necessitates the administration of medical care, dental care, hospitalization, or surgery to my child. Therefore, in event of injury or illness to my child, which necessitates emergency medical or dental care, I hereby authorize Shiva Robotics Academy and its staff in charge of the Shiva Robotics Academy Class to arrange any necessary emergency treatment including the administration of anesthetics and surgery to my child. I also understand that a parent/guardian will be contacted at the earliest possible moment in the event of an emergency relating to my child.
Medical, Dental, Health, and Insurance Responsibilities:
I understand and acknowledge that Shiva Robotics Academy cannot assume responsibility for determining the medical, dental, or health condition of my child. Therefore, I have consulted with a medical doctor and/or dentist, as I have deemed necessary, with regards to my child’s individual medical or dental issues or needs, and find my child physically and mentally fit to participate in the Shiva Robotics Academy’s Class. If my child is required to receive medical, dental, or hospital services during class, I am aware that Shiva Robotics Academy cannot and does not assume legal responsibility for payment of such costs; rather, I hereby assure Shiva Robotics Academy that I have assumed all risk and responsibility thereof and that my child has the necessary insurance to meet any and all needs for payment of these services during the Shiva Robotics Academy Class.
Permission to Use Photograph or Likeness:I understand that Shiva Robotics Academy offers school pictures two times a year, in the spring and fall. I further understand that I am under no obligation to purchase the photos that are taken of my child or pictures that my child may be in.
I also understand that Shiva Robotics Academy may take pictures of the children playing from time to time for use with a project or for production of promotional materials for Shiva Robotics Academy, its affiliates, and any of its partner organizations. I understand that pictures are sometimes used to help show parents what their children are doing during the day. I realize that photos may be displayed in the room from time to time and could possibly include my child. I also realize that my child might be in the background or play area with another child when a picture is taken and that it is possible that that particular picture might be sent home with the other child to show their parents what they are doing.
I agree to give permission for Shiva Robotics Academy to take photographs or video images of my child. I agree to allow these photographs to be displayed in my child’s classroom, on other classroom or center bulletin boards, or on Shiva Robotics Academy and our affiliate/partner organization social media/websites/Youtube Channel or to be used as mentioned above. I further agree to allow the center to use these photographs or video images in promotional or training applications.
I hereby give my permission to Shiva Robotics Academy to use my child’s photographic image, in whole or in part, for camp-specific public information and for marketing activities at the discretion of Shiva Robotics Academy. I understand that the photography remains the property of Shiva Robotics Academy.
□ Check this box if you do NOT give the above permission to use your child’s photograph or likeness.
I HAVE CAREFULLY READ THIS AGREEMENT AND I FULLY UNDERSTAND ITS CONTENTS AND SUBMIT IT OF MY OWN FREE WILL. I AGREE TO THE TERMS OF THIS AGREEMENT AND UNDERSTAND THAT IT CANNOT BE MODIFIED ORALLY.
NOTICE TO THE MINOR CHILD'S NATURAL GUARDIAN
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF SHIVA ROBOTICS LLC USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO RECOVER FROM SHIVA ROBOTICS LLC IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND SHIVA ROBOTICS LLC HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
