MINOR PARTICIPANT MEDICAL MISSION WAIVER AND RELEASE FORM

I, the undersigned, ____________________________________ (Name of Parent/Guardian), am the lawful

parent/guardian of ____________________________________ (Name of Child), born on __________________.
I hereby consent to and authorize the participation of my minor child in the medical mission
organized by Parola Inter-agency Network on November 16, 2023.

I understand and acknowledge that my minor child will receive optical, dental, and or medical
consultation services during the medical mission. I am fully aware that these services are being
provided voluntarily by licensed medical professionals and volunteers. In consideration of my
child's participation in this medical mission, I, on behalf of myself and my minor child, do hereby
acknowledge, agree to, and accept the following:

Assumption of Risk: I understand and acknowledge that the optical, dental, and medical
consultation services carry inherent risks, including but not limited to the risks associated with
medical procedures and treatments.

Release and Waiver: I, on behalf of my minor child, release and discharge PIAN, its members,
volunteers, and medical professionals from any and all liability, claims, demands, actions, or causes
of action arising out of or related to any injury, illness, or other medical conditions that my minor
child may incur during or as a result of the medical mission.

Photographic Release: I consent to the use of photographs or images of my minor child taken
during the medical mission for promotional, educational, or informational purposes, without any
compensation to my child or myself.

Emergency Contact Information: I have provided accurate and up-to-date emergency contact
information for my minor child, and I understand that this information will be used in case of
any emergency.

I have read this Waiver and Release Form in its entirety, and I fully understand its contents. I
agree to this document freely and voluntarily.

Parent/Guardian's Full Name: _________________________________

Parent/Guardian's Signature: _________________________________

Date: ____________________________