1. I understand that there are risks associated with the use of the pool. I am aware of these risks and agree that my child’s participation is at my/their own risk. I hereby release Faith Pediatric Rehabilitation P.L.L.C and Physical Therapy Care of Fort Bend, employees from any and all actions, costs, suits, demands, claims, damages, losses and liabilities connected to my participation in the activities of the therapeutic pool program at Physical Therapy Care of Fort Bend. This includes reasonable attorney’s fees of any type or kind whatsoever arising out of or caused by my child’s participations in any such activities. I also represent and warrant that I have obtained approval from my physician to participate in the following contraindications for pool participation: severe cardiac problems; uncontrolled seizures; open wounds; open trachea; infectious skin conditions; fever; urinary infection; diarrhea. My child is medically sound to pursue aquatic therapy. Initial _________
2. I give Faith Pediatric Rehabilitation P.L.L.C permission to discuss my child’s case with involved professionals. I understand that services are performed in a therapy clinic and in plain view of non-care related persons. Initial _________
3. I fully understand the rules and regulations of the pool, and will abide by them completely. I release Faith Pediatric Rehabilitation P.L.L.C from all future claims and causes of action occurring as a result of personal injuries sustained by the client as a consequence of using Physical Therapy Care of Fort Bend’s facilities. I agree to cooperate fully with any request of Physical Therapy Care of Fort Bend’s staff. Initial________
Name___________________________ Signature______________________ Date_____
Release to Discuss Your Child’s Session
I the parent (print name)_____________________ give my child’s therapist(s) permission to discuss his/her treatment session in any location within our office where there may be other clients and caregivers present.