1 1 3 1 0

S I R

W I N S T O N

S T .

B L D G

S A N

A N T O N I O ,

T X

7 8 2 1 6

( 2 1 0 )

5 2 5 - 8 8 5 1

O F F I C E F A X

( 2 1 0 ) 5 2 5 - 8 8 5 4

W W W . O U T R E A C H P E D I . C O M

OUTREACH PEDIATRIC THERAPY, INC.

Waiver of Liability

Initials

For the safety of your child Outreach Pediatric Therapy recommends all parents/caregivers to remain in the clinic at all times during therapy sessions. This allows for quick communication and decision making in the event of an injury or accident. I understand that if I chose to leave my child against the recommendation and policy of Outreach Pediatric Therapy, this may place my child at risk for delayed medical treatment in the event of an injury. Therefore, by signing below, I hereby acknowledge that these risks have been explained to me. I further agree to waive any and all claims or theories of liability against Outreach Pediatric Therapy in the event my child is injured, and a delay in treatment occurs as a result of my unavailability and/or decision to leave Outreach Pediatric Therapy during my childs treatment.

Initials

I understand the paragraphs above and have had all questions about this release answered before signing and agreeing to the above terms. _____________________________ Childs Name _____________________________ Parent/Legal Guardian Signature Cellular Phone # _______________ Emergency Contact Name: ______________________ Phone #: __________________ Relationship to child: _________________ Date: _____________________

Outreach Pediatric Therapy, Inc. All rights reserved

Revised: 12/27/11