Parental/Guardian Consent Form and Liability Waiver Child’s Name Birth date MM slash DD slash YYYY Child’s Name Birth date MM slash DD slash YYYY Child’s Name Birth date MM slash DD slash YYYY Parent/Guardian’s Name(s) Parent/Guardian’s Name(s) Dirección del Hogar Home PhoneWork PhoneCell PhoneI/We, the undersigned, are the parent(s)/guardian(s)of the above named child/children and I/we agree, in taking advantage of the child care services provided by Morehouse School of Medicine (“MSM”), to release and hold harmless MSM, its directors, offices, employees and consultants from any and all claims, demands, suits, cost, and charges in connection with or arising out of provision of the child care services, including, but not limited to, bodily harm or injury to my/our children, except only for loss, harm or injury occasioned by gross negligence or intentional misconduct by MSM. We/I hereby grant permission for MSM and its personnel full authority to take whatever actions they deem necessary regarding my/our child’s health and safety in the event I/we cannot be reached or in the situation where time is of the essence; and fully release MSM and its personnel from any liability in connection with those decisions. I/we grant permission for emergency treatment by a rescue squad, private physician and/or hospital or emergency health care facility staff, if needed. I/we acknowledge that MSM will take any such action in the best interest of my/our child and MSM will report such action to me/us as soon as possible. SignatureDate MM slash DD slash YYYY SignatureDate MM slash DD slash YYYY