Statement of Understanding

I (parent/guardian/caregiver) hereby make application to enroll my child in Peak Potential Therapy's Camp A.B.C.™ I hereby certify that he is of good moral character. I hereby also certify that I have given full disclosure concerning all medical, physical, and psychological conditions which might have relevance to the performance of my child. I also understand that I am liable for information that is false, misleading, or later found to be omitted concerning all such medical, physical, or psychological conditions and all suspensions, expulsions, or adjudications. I have no objection to publicity in conjunction with camp activities that involve my child/ward. I hereby certify that I will assume the necessary financial obligations. I understand and agree that no deductions or rebates will be made if he is withdrawn after the start of camp. No refunds of any kind will be provided if the camper fails to report to summer camp, or in the event of his withdrawal.

I (parent/guardian/caregiver) hereby release and hold harmless Peak Potential Therapy LLC including but not limited to Natalie (Holly) M. Reimann and all employees, agents, representatives from any and all claims, cost, damages, and liablities for any injuries sustained by myself or my minor child's or adult's participating in this summer camp program offered by Peak Potential Therapy. I understand that any fees charged for a program do not include accident, or personal insurance.

I have read, understand, and agree to the above Statement of Understanding:

YES NO

Photograph Release:

I (parent/guardian/caregiver) authorize Peak Potential Therapy to use and reproduce photographs, film and videotape taken of my child and to circulate same for advertising and publicity purposes of any kind.

YES NO