For Children

This form is to authorize Round Top Festival Institute, 248 Jaster Road, Round Top, TX 78954, their agents, representatives and employees [hereinafter "Institute"] to obtain emergency medical assistance and to provide transportation for the child herein below named, and to release the Institute from liability for injuries to children while on the Institute premises or otherwise in the care of the Institute staff members, such as in transporting the children.

In the event that I/we cannot make arrangements for emergency medical attention at the time of illness or accident of my child,

__________________________ (child’s name),

I hereby authorize any agent, representative or employee of the Institute to take my child to

Dr. ________________________ (specify name or indicate “ANY”)

Phone ______________________

Address _____________________________________________

or to       _____________________________________________ Hospital

where medication or medical procedures they may deem necessary for my child’s well being will be administered. The undersigned further agrees to be financially responsible for all such medical services, including the cost of defense and enforcement of this indemnity agreement.
I further understand and agree that the Institute, its agents, representatives or employees may administer simple first aid in the event of minor injuries, and family members or doctors will be called when in the discretion of the Institute personnel, it is deemed necessary.

I/we represent that I am parent/guardian of _________________________
and am fully responsible for the care and well being of the child. I agree that the Institute shall not be liable for any damages, claims or compensation of whatever nature (including liabilities for negligence, strict liability, or otherwise) that may arise to me of for my benefit, in the name of or for the benefit of the child, or in the name of or for the benefit of any other person as a result of personal injury to the child named above while the child is on the premises of the Institute or otherwise in the care of the Institute personnel, including such injuries sustained while the child is being transported to programs of the Institute.

I/we have read the foregoing and agree with it in all respects.

Signed on _________________________(Month/Day/Year)

Signature _______________________________________