Being ME
Muslimah Empowered
Women’s Conference
PLAY & PRAY CHILDREN’S CONFERENCE WAIVER
PAID: YES NO WRISTBAND: YES NO
Additional Comments: _____________________________________________________________________________
Name(s) of Children:
M F
Child’s Name Age Gender
M F
Child’s Name Age Gender
M F
Child’s Name Age Gender
M F
Child’s Name Age Gender
M F
Child’s Name Age Gender
Parent’s/Guardian’s Name Home Phone/Work Phone
Primary Emergency Contact (Same as above [ ]) Primary Emergency Phone
Allergies/Special Health Considerations/Current Medication
AUTHORIZATION FOR MEDICAL SERVICES
I, the parent/guardian of ______________________________________________ (insert the name of child/children),
hereby designate the Being ME Children’s Program to act on my behalf to authorize such hospitalization, medical
attention, and/or surgery as may be required in an emergency because of illness or injuries sustained by my child/ward
while participating in the Being ME Children’s Program activities. I hereby assume all financial responsibility for
hospitalization, medical attention, transportation, and surgery provided. I request that I be contacted within a reasonable
time in the event of illness or injury requiring medical services.
Parent’s/Guardian’s Signature Date
Being ME
Muslimah Empowered
Women’s Conference
RELEASE/INDEMNNIFICATION OF ALL CLAIMS AND COVENANT NOT TO SUE.
NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. By signing this agreement, you give up your right to
bring a court action to recover compensation or obtain any other remedy for any injury to you, your family or to your
property or for your or your family member’s death however caused arising out of your or your family member’s
participation of Being ME Children’s Program, now or any time in the future.
Governing Law: The laws of the Province of Ontario, Canada shall govern this Agreement and its performance. You
consent and submit to the exclusive jurisdiction of the courts of the Province of Ontario, Canada, in all disputes arising
out of or relating to the use of the Being ME Children’s Program and this Agreement.
Liability Disclaimer: The Being ME Children’s Program, its third party providers and distributors make no
representations, warranties, guarantees or conditions of any kind, express or implied, regarding the Being ME Children’s
Program, or any content or materials provided on the Being ME Children’s Program, or your use of the Being ME
Children’s Program or of any services provided through your use of the Being ME Children’s Program or otherwise by
the Being ME Children’s Program, all of which are provided on an "as is" basis.
I ACKNOWLEDGE AND AGREE that the participation of any program, including participation in the Being ME
Children’s program has inherent risks. I have full knowledge of the nature and extent of all risks associated with
exercising, running, playing, and the Being ME Children's Program, including but not limited to: GAMES, SONGS,
PRAYERS, EXERCISES, INSTRUCTION, IF ANY, AND ANY OTHER ACTIVITY ASSOCIATED WITH THE
BEING ME CHILDREN’S PROGRAM ON AND AFTER THE DATE HEREOF.
I further acknowledge that the above list is not inclusive of all possible risks associated with the program and that the
above list in no way limits the extent or reach of this release and covenant not to sue.
In consideration of my child’s participation in the Being ME Children Program, I, the undersigned user, agree to release,
indemnify, and hold harmless, on behalf of myself, my heirs, representatives, executors, administrators, and assigns
HEREBY DO RELEASE, INDEMNIFY, AND HOLD HARMLESS BEING ME CHILDREN’S PROGRAM. It
officers, agents, and employees (hereafter collectively referred to as " BEING ME CHILDREN'S PROGRAM") from any
cause of action, claims, or demands of any nature whatsoever, including but not limited to, a claim of negligence, which I,
my heirs, representatives, executors, administrators, and assigns may now have, or have in the future against BEING ME
CHILDREN'S PROGRAM, on account of personal injury, property damage, death, or accident of any kind, arising out of
or in any way related to my use of the BEING ME CHILDREN'S PROGRAM facility, whether that use is supervised or
unsupervised, however the injury or damage is caused, including, but not limited to the negligence of BEING ME
CHILDREN'S PROGRAM, its officers agents, and employees.
I hereby certify that my child is in good health and that my child has no physical limitations, which would preclude their
safe participation in the Being ME Children program. I further understand that the terms of this agreement are legally
binding and I certify that I am signing this agreement, after having read it.
I ASSUME ALL RISKS AND HAZARDS TO INCIDENTAL TO THE CONDUCT OF THE ACTIVITIES. I AM
THE PARENT OR GUARDIAN OF THE NAMED CHILD WHO IS A CANDIDATE TO BE PARTICIPATING
AT THE BEING ME CHILDREN'S PROGRAM. I HEREBY GIVE MY APPROVAL TO THE
PARTICIPATION IN ANY AND ALL OF THE ACTIVITIES OF THE BEING ME CHILDREN'S PROGRAM.
I give permission for photographs taken at Being ME Children’s Program may be used for publicity purposes.
_________________________________ ___________________
Signature of Parent/Guardian Date
