Consent Form Release From Liability And Indemnity

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CONSENT FORM, RELEASE FROM LIABILITY & INDEMNITY AGREEMENT
I/We, the undersigned parent(s) or guardian(s) of_________________________ , a minor, do
hereby CONSENT to his/her participation in the Newton Community Farm’s High School
Intern (hereafter referred to as the “Intern”) program for the weeks of
___
_____________, 20_____. I/We RELEASE and discharge the Newton Community Farm,
Inc., the City of Newton and its departments, officers, employees, and agents (hereinafter
collectively referred to as "Newton"), from any and all claims, damages, losses or expenses
of whatever kind or nature which I/we may have or acquire as the parent(s) or guardian(s) of
said minor arising out of or resulting, directly or indirectly, from said minor's participation in
the Intern program. I/We also RELEASE and discharge Newton from any and all claims,
damages, losses or expenses of whatever kind or nature which said minor may have or
acquire arising out of or resulting from, directly or indirectly, his/her participation in the
Intern program. I/We furthermore agree to defend and INDEMNIFY Newton against any
claim, damage, loss or expense of whatever kind or nature that Newton may have to pay that
arises from said minor's intentional, grossly negligent, or reckless acts or omissions while
participating in the Intern program.
I/We hereby authorize Newton's employee(s) or agent(s) who is supervising said minor to act
on our behalf in authorizing and consenting to emergency medical care for said minor if
he/she becomes ill or is injured while participating in the Intern program. This Authorization
and Consent may be presented to the appropriate emergency medical staff at such time as
emergency medical care is required. I/We hereby RELEASE and discharge Newton
Community Farm and Newton from any and all claims of any nature whatsoever, which may
arise out of the decision to provide emergency medical care.
_______________________________________________________________________
Signature of Parent or Guardian Date Relationship
_______________________________________________________________________
Signature of Parent or Guardian Date Relationship
THIS FORM MAY NOT BE ALTERED
Revised: 3/13/13
Greg Maslowe, Farm Manager
Newton Community Farm
617-916-9655

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