Food Allergy Liability Waiver and Release Form

Program Name: "Date Night" Program for Ages 5-12

Location: 1351 E Montclair, Springfield, MO 65804

Participant Information

Food Allergy Disclosure and Liability Waiver

I, the undersigned parent or legal guardian of the above-named child, acknowledge and agree to the following terms regarding my child’s participation in the "Date Night" program offered by Achievers Academy Springfield.

1. Disclosure of Allergies:
   I understand that Achievers Academy Springfield requires full disclosure of any known food allergies my child may have. I agree to provide accurate and complete information below.

1. I understand that while Achievers Academy Springfield will make reasonable efforts to accommodate food allergies disclosed in this form, it cannot guarantee an allergen-free environment.
2. Assumption of Risk:
   I acknowledge that despite precautions, there is an inherent risk of exposure to allergens that may trigger an allergic reaction in my child. I understand these risks and voluntarily assume full responsibility for any adverse reaction or illness resulting from my child’s participation in the program and consumption of any food provided.
3. Release of Liability:
   In consideration for my child’s participation in the program, I hereby release, discharge, and hold harmless Achievers Academy Springfield, its officers, employees, volunteers, agents, and representatives from any and all claims, demands, damages, rights of action, or causes of action arising out of or related to any allergic reaction, injury, illness, or damage resulting from exposure to allergens, whether known or unknown, during the program.
4. Medical Authorization:
   In the event of an allergic reaction or other medical emergency, I authorize Achievers Academy Springfield] and its representatives to provide or secure any necessary medical treatment for my child. I agree to be responsible for any costs associated with medical treatment, including medication, emergency services, and hospitalization.
5. Indemnification:
   I agree to indemnify and hold harmless Achievers Academy Springfield and its representatives from any claims, damages, losses, or expenses, including attorneys' fees, arising from any allergic reaction experienced by my child or any other individual related to food consumed by my child.

Acknowledgment and Agreement

I have read this Food Allergy Liability Waiver and Release Form, understand its terms, and agree to them voluntarily. I understand that by signing this form, I am waiving certain rights that I or my child might otherwise have. I agree to be bound by its terms and acknowledge that this waiver will be governed by the laws of the State of Missouri.