Medical Release & Consent

By allowing my Applicant to participate in Restoration Project Foundation Mentor Program I understand he/she will be meeting with a mentor 18 years or older who has been screened and trained by the Restoration Project Foundation. I understand that his/her participation in active events have inherent risk, including but not limited to, the risk of serious physical injury. The undersigned assumes that risk on his/her behalf.

Medical treatment for the Applicant may be authorized by Restoration Project Foundation Mentor Program staff member or volunteer as my agent at my sole expense. I further allow the Restoration Project Foundation Mentor Program to give any medical provider the name of my medical insurance and my policy number, both of which will be provided with this application and will provide Restoration Project Foundation Mentor Program with the most up to date insurance card.

In consideration of Applicant’s participation in any and all programs of the Restoration Project Foundation Mentor Program, the undersigned agrees on his/her behalf to defend, indemnify, and hold harmless the Restoration Project Foundation Mentor Program, their agents, servants, volunteers, Board of Directors and staff from any and all claims or damages arising out of (1) the Applicant’s participation in any and all programs, and (2) any act, omission or negligence of the undersigned. The undersigned releases the Restoration Project Foundation Mentor Program from any and all claims, damages and causes of action s/he ever had, now has or hereafter may have by reason of the undersigned’s participation in the programs of the undersigned’s time with the Restoration Project Foundation Mentor Program. This release includes all liability of injury, death, or other damage to me, my Applicant, family, estate, or heirs that may result from his/her participation in the project, including but not limited to transportation, and hold harmless any Restoration Project Foundation Mentor Program mentor, project staff, or its representatives, both collectively and individually, of any injury, physical or emotional.

This form, properly executed, must be submitted to the Restoration Project Foundation Mentor Program with the Applicant’s Mentor Program application and may be revoked at any time having the original of the form returned to the undersigned and a letter of revocation substituted therefore.

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