I, the undersigned, being either a parent with legal custody or the legal guardian of the minor whose name appears above, hereby authorize the student named above to participate in various events and/or activities with Vine Academy under the supervision of paid and/or volunteer leaders through August 31, 2027, and to be recorded and photographed for promotional purposes (including website postings). I further agree to personally pick up my minor promptly if, at the sole discretion of the leader responsible for the event, the minor is ill or a disruption to the mission of Vine Academy. Since this event is not on the Vine Academy campus, I, the undersigned Guardian(s), do also hereby give permission for my minor-Participant to ride in any vehicle designated by the adult in whose care the minor-Participant has been entrusted during the event. MEDICAL RELEASE: I, the undersigned, being an adult participant/parent with legal custody or the legal guardian of the minor whose name appears above, hereby authorize any adult person (paid or volunteer) with VINE ACADEMY of Gilroy, CA, into whose care the minor has been entrusted to, consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, dental diagnosis or treatment, and/or hospital care to be rendered to the minor under the general or special supervision of any member of the medical/dental staff and emergency room staff licensed under the provisions of the Medical Practice Act or Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It’s understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that efforts shall be made to contact me, the undersigned, prior to rendering treatment to the patient, but that any of the determined treatment will not be withheld if I cannot be reached. This authorization is given pursuant to California Civil Code section 25.8. If a personal physician is listed, every effort will be made to contact such physician. The signing of this release only gives the Vine staff or volunteers thereof the right to consent for treatment of minors/adults. In addition, if the above-mentioned medical treatment is provided, I, the undersigned Guardian(s), authorize any facility, which has provided treatment to the minor-Participant, to surrender physical custody of such minor to Vine Academy upon completion of treatment. It does not release me, the signee, from liability for medical costs arising from said treatment. It is understood that the releases provide no medical insurance for such treatment. I further agree to be liable for any expenses related to treatment performed under this release. I, the undersigned Participant/Guardian(s), will not sue or hold Vine Academy, its directors, officers, employees, volunteers, nor agents liable for any occurrence that may occur, including, but not limited to: accident, physical or emotional injury, during this event. I also understand that no warranty or guarantee has been made as to the result of or cure of treatment. This release shall remain in effect through August 31, 2027. I will inform Vine Academy immediately, in writing, of any change in the information presented on this form.
