RELEASE AND WAIVER OF LIABILITY REGARDING
CHILDREN WITH SEVERE ALLERGIES
This is a RELEASE AND WAIVER OF LIABILITY REGARDING CHILDREN WITH SEVERE ALLERGIES (hereinafter, referred to as the “Release”) made this ____ day of ______20__, by and between ________________________(“ the School”) and
______________________________________________________________________
Parent(s)/Guardian(s)
residing at _____________________________________________________, who are
the Parent(s)/Guardian of ___________________________________________.
(Child’s Name)
The School has been requested by the Parent(s)/Guardian(s) to enroll _________________, who
has a severe allergy to ___________________________________________________________
(Allergen[s])
Additionally, the School has been requested to administer medical treatment (including the administration of Epinephrine) to the child during certain situations when the child has come in contact with the allergen(s) as prescribed in writing on the child’s “Authorization For Administering Medical Treatment to Children With Severe Allergies,” (“the Authorization)
In consideration of the agreements and covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto hereby agree as follows;
1. Parent(s)/Guardian(s) hereby release and forever discharge the School, its employees and agents from any and all liability arising in law or equity as a result of employees or agents, including specifically, but not limited to, the child’s teacher, ___________ administering epinephrine or providing any medical treatment to the child relating to such child’s allergies.
2. This Release shall be governed by the laws of the State of Florida which is the location of the School in which the child is enrolled, excluding its choice of law provisions.
3. This Release supersedes and replaces all prior negotiations and all agreements proposed or otherwise, whether written or oral, concerning all subject matters covered herein. This instrument, along with the Authorization (including any additional physicians’ instructions or clarifications), which is hereby incorporated by reference, constitutes the entire agreement among the parties with respect to the subject matters discussed herein.
4. The reference in the Release to the term “the School” shall include _______________________________________, the Diocese of Orlando, and their affiliates, successors, religious directors, officers, employees, agents and representatives. The terms Parents(s)/Guardian(s) shall include the dependents, heirs, executors, administrators, assigns and successors of each.
5. If any staff member determines that administration of an injection of medication provided by the Parent(s)/Guardians or any other measure is necessary to counteract allergic reactions, the School shall be held harmless from any and all liability as a result of such action and the outcome of such administration or measure.
6. This Release also shall constitute an estoppel against any and all legal or equitable claims and the Parent(s)/Guardians shall further hold harmless and indemnify the School in the event any claim is asserted by any third party against the parties covered by this agreement. The indemnification includes all cost and attorneys fees incurred by the School.
7. If one or more of the provisions of the Release shall for any reason be held invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect of impair any other provision of the Release. This Release shall be construed as if such invalid, illegal or unenforceable provisions had not been contained herein.
SCHOOL
By: __________________________________
Name: ________________________________
Title: _________________________________
Date: _________________________________
PARENT (S) OR GUARDIAN (S)
By: __________________________________
Name: ________________________________
Relationship: ___________________________
Date: _________________________________