Parent/Guardian Information

I/We attest that the information provided in this application is true and correct to the best of my/our knowledge and abilities. Furthermore, I/We understand that the presence of inaccurate information in this application could result in re-evaluation or rejection of this application by the Growing Minds Foundation.

Child Information

Funding Request

Insurance Information

Uploads

A healthcare provider recommendation is required. Please download and print the provider recommendation form, have your child’s doctor, therapist, or provider complete it, then upload it here or have them email it directly to thegrowingmindsfoundation@gmail.com

Release and Disclaimer

The undersigned, by signing below, acknowledges, agrees to, and understands that this form includes a good faith waiving of certain invaluable rights in exchange for the providing of certain equipment and/or other devices and any and all other monetary support or help received by the undersigned, from the Growing Minds Foundation, and

all of their related entities, members, employees, officers and directors, attorneys, agents, successors, and assigns (all collectively referred to as “The Growing Minds Foundation”). By signing this form, the undersigned acknowledges that they are releasing the Growing minds Foundation and other parties of liability for themselves, any of their natural minor children, or minor children in their legal guardianship. The use of any equipment provided by the Growing Minds Foundation, even in the event of a

malfunction resulting in injury, may give rise to liability on the part of the Growing minds foundation and I/we hereby fully release any action I/we may have with regard to same. I/we recognize on behalf of myself/ourselves and any minor under control that the use of or participation with any equipment provided involves subjecting oneself to risk of injury, and I/we hereby agree to obey any and all safety standards and the instructions of the Growing Minds Foundation staff, as well as hold all entities or individuals involved with the Growing Minds Foundation free from liability. THE GROWING MINDS FOUNDATION is in no way endorsing or recommending a particular course of treatment

and that all treatment decisions should be made by the child’s physician and parents/guardians. THE GROWING MINDS FOUNDATION is in no way responsible for reclaiming, disposing of, maintaining or repairing any equipment provided. It is my/our sole responsibility as the recipient or recipient’s legal guardian(s) to maintain, repair and/or dispose of the equipment. Any costs that may be associated with the equipment, such as installation, delivery, labor, disposal, etc., that are not explicitly stated in writing from the Growing Minds Foundation as the Growing Minds Foundation responsibility, is my responsibility. Additionally, I/we, and not the Growing Minds Foundation, agree to be responsible for insurance with any and all costs connected therewith.

I/we understand that the involvement with the Growing Minds Foundation is voluntary. I/we assume the risk of any and all injuries, which may occur as a result of participating with the Growing Minds Foundation.

I/we grant the Growing Minds Foundation, their offices, employees, agents, attorneys, successors and assigns, the right to use, reproduce, assign and/or distribute photographs, films, videotapes, DVDs, sound recordings, including any print, electronic, broadcast or other type of photo/media that is normally considered media in the business or trade, involving myself or any individual under my/our control for use in the materials that the Growing Minds Foundation and its affiliates, may compile and/or distribute. I/we fully understand that there will be no form of compensation for any such use.

In the event that equipment, devices, assistance with therapeutic programs and any other type of item furnished to me, including all types of supports provided through this and any affiliate of the Growing Minds Foundation, it is expressly understood that the time provided or assisted has no warranty whatsoever from the Growing Minds Foundation, their officers, directors, employees, members, or other individuals associated with the Growing Minds Foundation (hereinafter collectively referred as “the Growing Minds Foundation”). It is expressly understood that the Growing Minds Foundation is merely a funding source and as such delivers no warranty and any malfunction or injury resulting from the use of anything provided by the Growing Minds Foundation carries no liability on the party of the Growing Minds Foundation. Additionally, the Growing Minds Foundation is not responsible for reclaiming, disposing of, maintaining, or repairing any of the items provided. It is the sole responsibility of the undersigned to maintain, repair, and/or dispose of the items provided. Any cost that may be associated with the item provided, including installation, delivery, labor, disposal, repair, replacement, etc. that are not explicitly stated on the application and/or award letter from the Growing Minds Foundation is the sole responsibility of the recipient’s legal guardian(s). The recipient is responsible for ensuring compliance with all codes and hereby releases the Growing Minds Foundation from such responsibility. Additionally, recipient is responsible for maintaining compliance with all applicable building codes, and/or federal, state, or local regulations.

Release of ALL CLAIMS (Liability Release)

I/we have read this form and are aware of and understand that in consideration of and in exchange for the right of myself or any minor child under my control to participate with the Growing Minds Foundation and I/we agree to indemnify and hold harmless, release and forever discharge, the Growing Minds Foundation and all their employees, officers and directors, attorneys, agents, successors and assigns from any and all actions, suits, claims, demands, judgments, damages and liability in law and equity which may arise as a result of my/our participation with the Growing Minds Foundation, including costs, and reasonable attorney’s fees. This release shall serve as a release not only of myself and any minors under my control but also to all heirs, executors, administrators, personal representatives, parents, guardians, and for all members of their family. As a parent of guardian signing for a minor it is agreed that I/we agree to these terms for the minor, for us individually, and as a parent or guardian. Any and all individuals signing this form acknowledge that the Growing Minds Foundation and its affiliates have relied upon the good faith execution and delivery of this form. The parties hereto signing this form assume the risk of any and all injuries, which may occur while participating with the Growing Minds Foundation.

I/we have read and understand this form, have had an opportunity to ask question, have had the opportunity to consult an attorney of my/our own choosing, and freely agree to the terms as expressed in return for participation with the Growing Minds Foundation in their programs. No oral agreements, either prior to or after signing this agreement shall control over this written agreement.