Date of Birth
Please indicate any changes in information since completing an original application (contact information, medical history, schooling, etc.)
Programs of Interest
Please indicate each course you plan to attend:
Authorization for Treatment of Participant – Consent, Release and Covenant
The undersigned parent/guardian represents to The Chicago Lighthouse that the minor named below is in his and/or her legal custody and control; that the undersigned desires said minor to participate in the programs of The Chicago Lighthouse; and that for purposes of said participation the undersigned agrees, authorizes and states as follows:
In case of medical or dental need or emergency, I (we) understand every effort will be made to contact parents/guardians of minors. In the event I (we) cannot be reached, I (we) undersigned, (participant over 18, or parents/guardians of)
I (we) authorize The Chicago Lighthouse and its officers or staff employees as agent(s) for the undersigned
to obtain and consent to any X-ray examination, anesthetic, medical, dental, surgical diagnosis, treatment and hospital
care which is deemed advisable, and is to be rendered to said minor under general or specific supervision of any surgeon
licensed under the provision of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed
under the provisions of the Dental Practice Act, whether such diagnosis of treatment is rendered at the office of said
physician or dentist or at the said hospital. I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment of my (our) child will be borne by myself (ourselves). We understand that no representation of such coverage exists or is intended by this form.
It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of The Chicago Lighthouse (as aforesaid) as my (our) agent(s), to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of his/her best judgment may deem available. This authorization shall remain effective while the minor is enrolled in any Chicago Lighthouse for People Who Are Blind or Visually Impaired program, unless sooner revoked in writing and delivered. The undersigned further releases The Chicago Lighthouse, and its officers, agents and employees, from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of The Chicago Lighthouse. I (we) further agree and covenant (for valuable consideration, receipt of which is acknowledged) that neither said person nor I (we) will institute any suit or action of damage, loss or injury of any kind, whether to person or property, whether to me (us), individually, or as parents/guardians relating to the programs or activities of The Chicago Lighthouse in which the minor participates.
I hereby authorize and give permission for the participant’s name, photograph, video and/or other identifying information (such as age, eye condition, etc.) to be used by The Chicago Lighthouse for publicity, collaborative or training purposes. I understand such uses may include brochures, newsletters, website entries, press releases or written stories without payment or any other compensation. I further understand some uses may be f or information and material sent to other organizations/companies (newspapers, television, radio, conference presentations, etc.) and that the materials will become the property of The Chicago Lighthouse and will not be returned.
Release of Information
I hereby authorize and give permission to T he Chicago Lighthouse to obtain and/or provide information to school district(s) , optometrist/ophthalmologist and/or Bureau Blind Services (BBS) for programming and collaboration regarding the participant listed below.
I hereby authorize and give permission for the participant identified below to participate in any off-site activities as a part of the selected programs. I understand such activities will be provided in a vehicle owned or rented by The Chicago Lighthouse and will be accompanied by a Chicago Lighthouse staff member.
I hereby authorize and give permission to T he Chicago Lighthouse to provide transportation for the participant identified below during Chicago Lighthouse programs for purposes of participating in programming and off- site activities.
I have read this release and agree to all stated. When Submitted electronically, your printed name serves as your signature. This is VALID FOR ONE CALENDAR YEAR. (Sign participant name if over 18 OR parent/guardian of a minor)