PARENT/CAREGIVER INTAKE PAPERWORK REQUIRED
To complete your registration and prior to attending any sessions, please email info@phoenixtx.org to schedule an appointment to complete the required intake forms. Thank you - we look forward to serving you and your child!
PARTICIPANT AGREEMENT & RELEASE
Including Acknowledgement and Assumption of Risks and Agreements of Release and Indemnity
I, the participant, or the parent or legal guardian (either, “Parent”) of the participant, if the participant is a minor (under eighteen years of age), for and in consideration of the services of Phoenix Center/Camp Phoenix acknowledge and agree as follows:
1. Activities and Risks: Phoenix Center/Camp Phoenix program services (both, referred to as “program” in this agreement) involve a variety of activities including warmups, discussions/debriefings, games, group initiatives (physically and cognitively), therapeutic activities, and moving on, around, and over high and low challenge ropes course elements, zip lines, aerial static ropes courses, and other structures at heights ranging from six inches to fifty feet or more. The level of participation is always entirely voluntary and a matter of individual choice and for all aspects of the program. Management of risks is an important priority in the facilitation of all levels of programming, however accidents do occur. Risks include risks associated with motor vehicle travel, both to and from program sites and to the site of medical care; all elements of nature, falls, heat stroke, heat exhaustion and lightening; communicable diseases; all diseases associated with exposure to insects, reptiles and animals; errors in judgment, by youth, volunteers, staff, or any contract employee of Phoenix Center/Camp Phoenix; and all other risks associated with all Phoenix Center/Camp Phoenix programs and activities. Participants may incur cuts, fractures, insect and reptile bites, and trauma from falls or contact with persons, animals (such as horses) or objects; heat and cold from exposure to natural elements, emotional upset or psychological stress, injury, fatigue; and in rare cases, death, including death while in a motor vehicle. Participants may also experience other risks that may or may not be anticipated by participants and staff. These risks are inherent in Phoenix Center/Camp Phoenix programming and in moving about the facilities where these activities are offered - that is, without such risks the program would lose its value and appeal.
2. Medical Issues & Costs: Phoenix Center/Camp Phoenix program activities are designed to be physically and emotionally demanding, for participants of average mobility and strength who are in reasonably good health. Certain medical conditions may increase the inherent risks of the experience and cause participants to be a danger to themselves or others. These potentially dangerous conditions include obesity, high blood pressure, cardiac and coronary artery disease, pulmonary problems, pregnancy, arthritis, tendonitis, or other joint and muscular-skeletal problems, seizure disorders, asthma, allergies, diabetes, impaired balance, eyesight, or hearing, and other physical, psychological and psychiatric disorders or other health conditions. Participants, including Parent/Guardian if the participant is a minor, must carefully consider these issues before choosing to participate, and fully inform Phoenix Center/Camp Phoenix staff of any potentially dangerous condition prior to participating in the program’s activities. By accepting a participant with a disclosed condition, Phoenix Center/Camp Phoenix is NOT representing that it can, or will, successfully manage an event arising out of that condition. Unless notified otherwise in writing, Phoenix Center/Camp Phoenix will assume that the participant is physically and emotionally capable of participating in all program activities without being a danger to themselves or others. Participants, or Parent/Guardian, understands they are solely responsible for any medical services that Camp Phoenix cannot accommodate. Participant (or their Parent/Guardian) is responsible for the cost of any necessary emergency transportation or medical service for the participant.
3. Acknowledgment and Assumption of Risks: I have been informed of and understand the nature of the program offered by Phoenix Center/Camp Phoenix - and its inherent and other risks - and that participation is entirely voluntary. I acknowledge and assume ALL the risks of being enrolled in and participating in the program. If I am signing this document as a Parent, I have discussed the activities and their risks with my child who understands and wishes to participate, nevertheless. Please notify the Phoenix Center in writing (24 hours in advance of the program date) if there are any specific activities in which the participant can NOT participate. Release and Indemnity: I, an adult participant, or Parent of a minor participant (if Parent, for myself and, to the extent allowed by law, on behalf of the minor), hereby agree to release and indemnify (that is, defend and pay or reimburse) Phoenix Center/Camp Phoenix, its owners, officers, directors, employees, volunteers and agents (the “Released Parties”) with respect to any and all claims, of whatever nature, including for property damage and personal injury, emotional trauma and death, which I or my minor child might incur or cause while enrolled or participating in a program of Phoenix Center/Camp Phoenix. This agreement of indemnity includes claims of members of my, or the child’s, family for losses suffered by me or the child; and claims of third parties, including co-participants, for any injury or loss claimed to be caused in whole or part by me or the child. These agreements of release and indemnity include claims arising in whole or in part from the negligence (but not the gross negligence) of a Released Party. These agreements of release and indemnity include, but are not limited to, claims based in whole or part on the NEGLIGENCE of a Released Party and extend to all costs and attorney’s fees incurred by Camp Phoenix / Phoenix Center.
4. Medical Care: In the event of a medical emergency, Phoenix Center/Camp Phoenix is authorized to provide or obtain such medical care for the participant (minor child or myself), as it deems necessary, at my expense.
5. Photo Release: Participant, for him/herself and on behalf of a child, gives permission and consents to the taking of video, photographs, or interviews, and agrees that Camp Phoenix may use such photographs and video in promotional materials produced by Camp Phoenix/Phoenix Center in the future.
Yes/Si No Initial Here
Phoenix Center/Camp Phoenix reserves the right to exclude anyone from participation, for medical, safety, or other reasons it deems appropriate. I acknowledge that I have been given the opportunity to ask questions regarding any aspect of this agreement, and by signing below I acknowledge that I have read completely and fully understand all aspects of this agreement and agree to its terms.
This agreement, including the agreements of release and indemnity, is intended by me to be binding, including on my or the minor child’s estate and heirs, to the fullest extent allowed by law.
CONFIDENTIALITY
Your confidentiality is extremely important to us. We will not disclose any of your information, including your status as a client at The Phoenix Center, to anyone who is not an employee of the Phoenix Center, without your written consent, with exception of the following:
- If there is suspicion of abuse to a child, an individual who is age 65 or older, or an individual with a disability, we will report our suspicions to Child Protective Services or Adult Protective Services as mandated by Texas law.
- If an individual wishes to harm himself or herself or another individual, we reserve the right to break confidentiality in order to create a Safety Plan and seek help and protection for the individual and others.
- If client records are subpoenaed by a court of law, we are required to release these records as detailed in the subpoena.