Event Waiver | Arizona Institute For Autism

Event Waiver

We are excited for you to join us! Your child has been invited to attend a party or event hosted by Arizona Institute for Autism (AIA). This event will take place under the guidance and supervision from one of our trained providers or volunteers from Arizona Institute for Autism.

Note: This form must be filled out and signed before participants are allowed to take part in any activities or events hosted by Arizona Institute for Autism (AIA). For questions regarding event waivers, please email services@abaclinicaz.com.

Event Liability Waiver

Name of Event

General Information

Child's First Name

Child's Last Name

Age

Date of Birth

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Emergency Contact

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Do you have permission to participate in physical and program relatated activities?

Yes

Please specify anything we should know about (health concerns/learning disabilities)

Please specify anything we should know about allergies (food/medications)

Initials

Note: Waiver must be signed per person/child attending the event listed above.

I declare that the info I’ve provided is accurate & complete

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

Thanks for submitting!

480.687.7099

Event Liability Waiver

General Information

Parent/Guardian Information

Emergency Contact

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